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PROTOZOA 


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ERRATA. 

Page  II.     Insert  vertical  line  under  Telosporidia   to  join  transverse  line 
embracing  Gregarinida,  Hsemosporidia,  and  Hremogregarinida. 

Page  51,  third  paragraph.     For  "  infected  "  read  "  infections  with." 
Page  1 18,  line  9.     "  Become  "  at  the  beginning  of  line  instead  of  at  the  end. 
Page  130.     For  "  thieleri  "  read  "  theileri." 

Page  137,  last  paragraph.     For  "  trypanosomes"  read  "  trypanosomiasis." 
Page  138,  fourth  paragraph.     After  "arista"  insert  "and  are." 
Page  142,  last  line  but  one.     After  "  whole  of"  insert  "  the." 
Page  154,  first  line.     After  "acute"  insert  "  :  " 
Page  170,  third  line.     After  "  It  is"  insert  "at." 
Page  190.     For  "  Chapter  XIV.  "  read  "  Chapter  XV." 
Page  197,  in  table,  fourth  line.     For  "  1-2  days  "  substitute  "  I-2." 
Page  213,  second  paragraph,  line  3.     After  "  neighbourhood  "  insert  "  of." 
Page  225,  first  paragraph.     For  "  McAllum  "  read  "  McCallura." 
Page  229,  seven  lines  from  bottom.     For  "  chelicera  "  read  "appendage." 
Page  230,  seventh  line.     For  "  Ixodinse"  read  "  Ixodse." 
Page  234,  second  paragraph.      For    "  veins  "   read    "  vein."      Fifth    para- 
graph :  for  "  fig.  24"  read  "  fig.  23." 

Page  246.     For  "  Hsematobia  pluvialis  "  read  "  Hsematopota  pluvialis.' 
Pages  252  and  258.     For  "  Marchand  "  read  "  Marchoux." 


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in  2010  witii  funding  from 

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http://www.archive.org/details/tropicalmedicine01dani 


TROPICAL 
MEDICINE    AND    HYGIENE 


TROPICAL   MEDICINE 


AND 


HYGIENE 


BY 


C.     W.     DAN  I  E  LS 

M.B.Cantab.,  M.R.C.P.Lond. 


Director  London  School  of  Tropical  Medicine  ;  Lecturer  on  Tropical  Diseases, 
L^ondon  Hospital ;  Assistant  Physician,  Albert  Dock  Hospital,  Seamen's  Hospital 
Society  ;  formerly  Director  Institute  for  Medical  Research,  Federated  Milay 
States;  Metnber  of  Royal  Society  Malaria  Commission,  and  in  the  British 
Guiana,  and  Fiji  Colotiial  Medical  Services 


E.    WILKINSON 

F.R.C.S.Eng.,  D.P.H.,  D.T.M.  &  H.Camb.,  Major  I. M.S. 

Formerly  Chief  Plague  Medical  Officer,  Punjab;  Acting  Sanitary  Commissioner, 
Punjab  ;  and  Professor  of  Hygiene,  Medical  College,  Lahore 

In  Three  Parts,  with  Coloured  and  other  Illustrations 

Part  L 
DISEASES     DUE     TO     PROTOZOA 


NEW     YORK 

WILLIAM   WOOD   AND   COMPANY 

MDCCCCIX 


V,    \ 


PREFACE. 

The  exigencies  of  tropical  practice  require  most 
medical  men  to  be  practical  sanitarians  as  well  as 
clinicians. 

It  is  with  this  in  view  that  in  the  present  work,  while 
due  attention  has  been  paid  to  the  clinical  features,  treat- 
ment and  nursing  of  tropical  diseases,  special  prominence 
has  been  given  to  their  etiology  and  prevention. 

Owing  to  the  recent  advances  in  the  knowledge  of  the 
etiology  of  many  tropical  diseases  the  subject  of  their 
prophylaxis  is  a  very  promising  one,  since  the  general 
principles  on  which  eiiticient  and  economical  preventive 
measures  should  be  based  are  now  well  understood. 

In  the  application  of  such  general  principles  local 
conditions  must  be  carefully  considered,  and  thus  in 
describing  the  various  methods  to  be  adopted  those 
suitable  for  certain  localities  have  been  given  as  types. 

In  the  spread  of  many  tropical  diseases  intermediate 
hosts  play  an  important  part,  and  the  life-history  of  such 
hosts,  often  insects,  has  been  considered  at  some  length, 
as  a  knowledge  of  this  subject  is  essential  to  the  proper 
understanding  of  the  rationale  of  the  preventive  measures 
proposed. 

An  attempt  has  been  made  to  group  the  diseases  treated 
of  according  to  their  known  or  probable  causation. 
Thus,  in  the  first  part  those  diseases  are  dealt  with  which, 
like  Malaria,  are  known  to  be  due  to  Protozoa,  and  others, 
such  as  Yellow  Fever,  which  are  probably  due  to  such 
organisms. 

In  the  second  part  diseases  due  to  the  higher  forms 
of  animal  life  are  considered. 

The  third  part  is  devoted  to  bacterial  diseases,  to  the 


IV.  PREFACE 

effects  of  certain  animal  and  vegetable  poisons  and  to 
certain  diseases  the  causation  of  which  is  unknown  or 
but  imperfectly  understood. 

The  advantages  of  this  arrangement  are  considerable, 
as  the  general  outline  of  the  prophylactic  measures 
required  differs  for  the  diseases  described  in  each  part. 

Thus  the  measures  described  in  the  first  part  are 
mostly  directed  against  arthropoda,  insects  or  arachnida, 
which  act  as  intermediate  or  alternative  hosts  for  the 
malarial  and  other  protozoal  parasites.  The  measures 
described  in  the  third  part,  including  as  they  do  those 
for  dealing  with  cholera,  enteric  fever  and  plague, 
involve  the  consideration  of  the  protection  of  water 
supplies,  the  disposal  of  sewage,  disinfection  and  other 
sanitary  problems  ;  while  the  measures  dealt  with  in  the 
second  part  include  some  directed  against  insects,  as  in 
the  case  of  filariasis,  and  others,  e.g.,  those  for  the  preven- 
tion of  endemic  hsematuria  and  ankylostomiasis,  dealing 
with  the  water  supplies  and  sewage  disposal  :  in  both 
cases,  however,  involving  somewhat  different  problems 
from  those  discussed  in  the  other  two  parts  of  this  work. 

Suitable  technical  methods  of  a  simple  character,  as 
well  as  data  and  measurements  in  common  use,  are  given 
in  an  appendix  to  each  part. 

We  are  much  indebted  to  numerous  friends  and  past 
students  of  the  London  School  of  Tropical  Medicine 
for  valuable  hints  and  aid  in  revision  of  proofs.  Major 
J.  B.  Smith,  Major  J.  H.  McDonald,  of  the  I. M.S., 
Dr.  Venis,  and  Dr.  H.  B.  Newham  must  be  specially 
mentioned.  The  charts  used  for  the  illustrations  are  in 
most  instances  those  of  patients  at  the  Albert  Dock 
Hospital  of  the  Seamen's  Hospital  Society,  to  which  is 
attached  the  London  School  of  Tropical  Medicine. 


CONTENTS. 


PAGK 


ClTAI'lKR    I. 

Introductory,  Classification,  and  Life  History  of  I'rotozoa       ...  i 

Chaptkr  II. 
Sporozoa,  General  ...  ...  ...  ...  ...         12 

Chapter  III. 
Malaria,  Benign  Tertian  and  Quartan  ...  ...  ...         15 

Chapter  IV. 
Subtertian  Malaria,  Pathology,  Treatment,  Complications      ...         22 

Chapter  V. 
Parasites  of  Malarial  Fevers,  Varieties  and  Species  ...  ...         48 

.Chapter  VI. 
Prevention  of  Malarial  Fevers,  Mosquitoes  ...  ...         65 

Chapter  VII. 
Black  water  Fever  ...  ...  ...  ...  ...         87 

Chaptf:r  VIII. 
Piroplasmosis,  General    ...  ...  ...  ...  ...       105 

Chapter  IX. 
Yellow  Fever,  Clinical  Course  and  Prevention  of      ...  ...        109 

Chapter  X. 
Flagellata,  General  ...  ...  ...  ...  ...        123 

Chapter  XI. 
Human  Trypanosomiasis,  Sleeping  Sickness  ...  ...        131 

Chapter  XII. 
Kala-azar  ...  ...  ...  ...  ...  ...       144 

Chapter  XIII. 
Oriental  Sore      ...  ...  ...  ...  ...  ...       167 

Chapter  XIV. 
Relapsing  Fever,  Indian,  Clinical  Course,  and  Etiology  ...       172 

Chapter  XV. 
Tick  Fever,  and  other  varieties  of  Relapsing  Fever  ...  ...       190 

CtrAPTER    XVI. 
Diseases  due  to  Spirochtetas  in  the  Tissues,  Syphilis,  Yaws, 

Granuloma  of  the  Pudenda       ...  ...  ...  ...       199 

Chapter  XVII. 
Intestinal  Diseases  due  to  Protozoa,  Amcebina  ...  ...       217 

Appendixes. 
(i.)  Notable    Dates  — •  (ii.)    Important    Measurements  —  (iii.) 
Classification   of  Diptera — (iv.)  Ticks — (v.)   Further  Sub- 
division of  Diptera  ...  ...  ...  ...  ...       225 


Tropical  Medicine  and  Hygiene 


CHAPTER  I. 
INTRODUCTORY. 


The  term  Tropical  Diseases  is  a  convenient  one  though 
not  capable  of  logical  definition.  Few  diseases  are  limited 
to  the  Tropics  or  even  subtropical  regions.  As  employed 
in  this  work,  it  is  meant  to  include  all  diseases  which  are 
not  commonly  seen  or  recognized  in  England  but  which 
are  prevalent  in  tropical  regions,  and  a  few  other 
diseases  which  present  peculiar  characters,  or  require 
special  prophylactic  measures  in  the  Tropics. 

The  peculiar  distribution  of  many  of  the  diseases  met 
with  in  the  Tropics  is  due  to  the  fact  that  the  parasites 
causing  them  require  special  conditions  for  their  extra- 
corporeal existence.  These  conditions  in  the  case  of 
parasites  such  as  ankylostomes,  which  do  not  require 
an  intermediate  host,  are  mainly  warmth  and  moisture. 
Where,  however,  the  parasites,  like  those  of  malaria, 
require  an  alternative  host  for  their  development,  the 
conditions  determining  the  distribution  of  disease  are  not 
purely  meteorological,  but  include  various  other  factors 
affecting  the  alternative  hosts — in  that  instance,  certain 
species  of  mosquitoes.  The  other  factors  include  the 
presence  or  absence  of  special  soil,  of  water  suitable  for 
breeding  places,  of  suitable  food  for  larvje,  and  so  forth. 
The  absence  of  natural  enemies  of  larvae  or  adults  has 
also  to  be  considered. 

The  distribution  of  such  alternative  hosts  and,  there- 
fore, of  their  parasites  and  the  diseases  caused  by  them, 
has  a  great  tendency  to  be  local  and  apparently  erratic, 


.2  TROPICAL   MEDICINE   AND   HYGIENE 

and  to  vary  from  time  to  time  without  any  obvious 
reason.  With  closer  study  the  reasons  for  such  varia- 
tions can  sometimes  be  traced.  The  varying  results  of 
prophylactic  measures  directed  against  such  diseases, 
though  on  the  whole  satisfactory,  are  explained  by  the 
variations  in  these  factors. 

The  distinction  between  plants  and  animals,  so  obvious 
in  the  higher  members  of  these  kingdoms,  is  less  definite 
in  the  unicellular  organisms.  Such  distinctions  as  the 
presence  or  absence  of  chlorophyll,  the  absorption  or 
assimilation  of  nitrogen  and  carbon  from  their  inorganic 
compounds,  or  only  from  higher  organic  compounds, 
are  not  conclusive.  Those  organisms  most  closely  related 
to  the  vegetable  kingdom  and  those  that  appear  to  be 
animal  may  either  be  motile  or  non-motile.  In  so  many 
instances  is  it  impossible  to  determine  whether  the  lowly 
unicellular  organisms  are  animal  or  vegetable,  that 
Haeckel  proposes  to  make  a  separate  kingdom  of  such 
forms  which  he  calls  Protista. 

The  unicellular  organisms  approximating  in  most  of 
their  characters  to  the  animal  kingdom  are  known  as  the 
Protozoa. 

In  the  warmer  countries  the  diseases  due  to  the  para- 
sites with  characters  in  the  main  animal  are  of  more 
special  importance  than  those  caused  by  parasites  of  the 
same  division  in  cold  climates. 

The  protozoa  for  this  reason  are  first  considered. 
Protozoa  are  unicellular  organisms.  The  cells  may  be 
aggregated  together  in  mass  or  may  occur  singly. 
Frequently  parts  of  the  cells  are  specially  modified  for 
special  purposes,  such  as  locomotion,  so  that  flagella  or 
cilia  are  formed,  whilst  in  other  instances  a  part  only 
of  the  cell  is  contractile  and  exhibits  amoeboid  movement. 

Many  of  the  protozoa  are  non-parasitic ;  others  are 
parasitic  only  in  the  lower  animals.  Some  are  parasitic 
during  a  portion  only  of  their  existence,  whilst  others  are 
parasitic  in  entirely  different  animals  during  the  different 
stages  of  development. 


INTRODUCTORY  3 

It  is  proposed  to  consider  in  detail  only  the  protozoa 
parasitic  in  man,  with  brief  reference  to  protozoa  parasitic 
in  other  animals. 

The  knowledge  of  disease-causing  protozoa  is  advancing 
so  rapidly  that  some  information  as  to  parasites  of  other 
animals  may  at  any  time  become  of  importance  in  human 
pathology. 

The  Protozoa  are  divided  into  four  groups  : — 

(r)  Sarcodina  include  all  forms  which  move  by  the 
protrusion  of  protoplasm  either  as  blunt  and  broad  pro- 
cesses or  sharp  and  thin  processes.  They  may  be  naked 
or  covered  in  part  with  shells.  Multiplication  is  by  bud- 
ding or  fission  ;  occasionally  spores  are  formed. 

(2)  Mastigophora  or  FlagcUaia  are  provided  with  motile 
apparatus  specialized  for  the  purpose  and  consisting  of 
one  or  more  flagella.  All  parts  of  the  cell  enter  into  the 
formation  of  the  flagellum.  The  body  is  usually  of  a 
well-defined  shape  and  covered  with  a  cuticle  or  mem- 
brane.    Multiplication  is  by  longitudinal  fission. 

(3)  Sporozoa  are  unicellular  parasites  living  during  a 
portion  of  their  life  in  cells  and  multiplying  by  the 
division  of  the  whole  or  part  of  the  protoplasm  into 
young  organisms  commonly  called  "  spores,"  more  cor- 
rectly termed  "  merozoites." 

(4)  CiUata  {Infusoria).  The  motor  apparatus  is  in  the 
form  of  cilia  which  may  be  either  simple  or  united  into 
membranes.  These  are  formed  from  the  ectosarc  only. 
Reproduction  is  effected  by  transverse  division  or  budding. 

Of  these  classes  it  will  be  convenient  to  consider  first 
the  Sporozoa. 

Recent  researches,  especially  those  of  Schaudinn,  have 
gone  far  to  throw  doubt  on  this  classification,  for  his 
work,  if  confirmed,  would  prove  that  the  distinction 
between  the  flagellata  and  the  sporozoa  is  not  a  sound 
one,  as  flagellates  have  a  quiescent  stage  when  thev 
resemble  sporozoa.  Much  more  work  is  necessary  in 
connection  with  the  protozoa  and  their  sexual  cycles  and 
transformations  before  we  can    safely  alter    the   present 


4  TROPICAL   MEDICINE   AND   HYGIENE 

classification,  and  any  premature  attempts  at  regrouping 
these  organisms  are  to  be  deprecated. 

Development  and  Life-history. — This  is  not  known  in 
all  the  genera,  but  where  it  is  fully  known  two  methods 
of  multiplication  can  be  shown  to  occur — asexual  or 
vegetative,  and  sexual.  As  types  of  the  life-histories  and 
methods  of  reproduction  of  the  sporozoa  those  of  coccidia 
and  of  the  parasites  of  malaria  may  be  taken  as  examples. 

In  the  coccidia  entrance  to  the  warm-blooded  host 
is  gained  through  the  alimentary  canal.  The  young 
coccidia  spores,  sporozoites,  are  set  free  from  the  cyst  in 
which  they  are  contained  by  the  action  of  the  digestive 
juices  and  penetrate  into  the  epithelial  cells  of  the  intes- 
tinal mucosa,  or  of  one  of  the  appendages  of  the  intes- 
tine such  as  the  bile  passages  and  the  liver. 

When  the  young  coccidia  have  entered  such  a  cell 
they  grow  until  they  have  entirely  filled  and  destroyed  it. 
Division  of  the  protoplasm  of  the  coccidium  now  takes 
place.  The  outer  part  of  this  has  formed  a  cyst  wall,  and 
thus  a  cyst  is  formed  containing  a  large  number  of  young 
coccidia  or  spores.  The  cyst  wall  then  ruptures,  the 
young  coccidia  are  liberated  and  pass  into  other  intes- 
tinal or  hepatic  cells.  The  process  is  repeated  over  and 
over  again,  and  massive  tumours  are  thus  formed  by  the 
coccidia  which  have  multiplied  asexually.  Coccidia  which 
develop  into  asexual  forms  are  known  as  "  schizonts." 
Some  of  the  spores  of  young  coccidia  develop  in  a  dif- 
ferent manner.  No  division  of  the  cell  contents  takes 
place,  but  the  protoplasm  remains  undivided  with  a 
single  nucleus.  A  weak  spot  in  the  cyst  wall,  known 
as  the  micropyle,  is  present.  Such  forms  are  the  female 
forms,  inacrogametes,  of  the  coccidia.  Again,  in  other 
coccidial  cells  when  they  have  reached  their  maximum 
stage  of  growth,  the  cell  contents  divide  into  a  mass  of 
bodies  smaller  and  more  actively  motile  than  the  spores. 
The  small  actively  motile  bodies  are  the  male  fertilizing 
elements  equivalent  to  spermatozoa,  and  are  known  as 
microgametes.     When  the  cyst  containing  them  ruptures 


INTRODUCTORY  5 

the  microgamctes  are  set  free  and  penetrate  through   the 
micropyle  of  the  macrogamete  and  fertihze  it. 

In  the  fertihzed  macrogamete,  now  known  as  the 
.oocyst,  various  changes  occur  and  the  micropyle  is  closed 
so  that  the  cyst  wall  is  complete.  The  cyst  is  discharged 
and  passed  with  the  faeces  of  the  host.  Development 
of   the    contents  takes  place,  the  cell  mass  divides   into 


Fig.  I. — Diagram  of  development  of  Coccidia.  Endogenous  life  includes 
the  asexual  cycle  and  the  fertilization  of  the  macrogamete  by  the  microgamete. 
The  further  development  does  not  require  an  alternate  host.  It  takes  place  on 
the  ground. 

four,  and  in  each  of  these  four  divisions  two  spores — 
"  sporozoites  "—are  formed.  This  stage  of  development 
takes  place  in  the  oocysts  as  they  He  on  the  ground,  no 
host  being  necessary  in  this  stage.  This  is  the  sexual 
form   of   multiplication.      Ultimately    when    the    cyst  is 


6  TROPICAL   MEDICINE   AND    HYGIENE 

swallowed  by  a  suitable  host  the  capsule  is  dissolved,  the 
sporozoites  are  liberated  in  the  alimentary  canal  and 
enter  cells  in  the  mucosa  or  pass  up  the  bile  ducts  in 
the  liver  and  there  recommence  the  cycle  of  events 
described,  multiplying  asexually  to  form  massive  tumours, 
or  becoming  sexual  forms,  gametocytes,  male  or  female. 
This  protozoal  infection  is  common  in  rabbits ;  it  has 
been  described  in  man,  but  is  certainly  extremely  rare. 
It  forms  a  good  example  of  a  sporozoal  organism,  parasitic 
during  its  stages  of  growth  and  asexual  multiplication, 
but  not  throughout  the  whole  of  its  sexual  development 

(fig.  I.) 

The  general  plan  of  development  of  the  parasites  of 
malaria  resembles  this  to  some  extent,  but  there  are 
important  differences. 

The  young  parasites  introduced  by  the  mosquito  into 
the  human  blood  enter  the  red  corpuscles.  In  these 
red  corpuscles  there  is  first  a  stage  of  growth  until 
the  maximum  size  is  attained.  No  cyst  is  formed,  but 
the  remnants  of  the  red  corpuscle  act  as  a  cyst  wall. 
When  the  full  size  is  attained  the  protoplasm  of  the 
parasite  divides  into  a  mass  of  rounded  bodies — the  spores 
or  "  merozoites,"  which  are  set  free  by  the  rupture  of  the 
red  blood  corpuscles  and  rapidly  enter  other  red  cor- 
puscles in  which  the  process  of  development  is  repeated, 
ending  in  a  further  liberation  of  spores.  This  process 
of  asexual  multiplication  resembles  the  similar  process 
in  the  coccidia,  with  the  exception  that  no  cyst  wall  is 
formed,  and  that  the  host  cells,  the  red  corpuscles,  are  in 
movement  in  the  blood,  so  that  the  parasites  are  scattered 
and  do  not  form  massive  tumours.  Asexual  multiplica- 
tion of  the  parasite  of  malaria  may  be  continued  for  years 
but  not  indefinitely. 

A  certain  number  of  young  parasites  do  not  go  on  to 
the  formation  of  spores  but  become  potentially  sexual 
forms  —  gametocytes.  These,  when  mature,  can  be 
recognized  as  differing  more  or  less  in  structure  and 
appearance    from    the    parasites    which    are    to    divide 


INTRODUCTORY  7 

asexually — sporocytes — corrcspoiidin;^    to    the    schizoiits 
of  the  coccidia. 

No  active  sexual  processes  take  place  in  man.  The 
gametocytes  do  not  undergo  development  unless  re- 
moved from  the  human  body.  When  their  environ- 
ment is  chans^ed,  as  it  is  when  the  blood  is  shed,  or 
more  certainly  when  it  is  sucked  up  into  the  stomach 
of  a  mosquito,  the  gametocytes  become  actively  sexual 
and  lose  the  protection  of  the  remnants  of  the  red  blood 
corpuscles.  Some  of  them,  the  females  or  macrogametes, 
are  passive  and  receptive,  and  except  for  the  extrusion 
of  small  rounded  masses,  the  polar  bodies,  change  little 
in  appearance,  whilst  .others,  the  male  forms,  throw  out 
fiagella  which  are  actively  motile  and  soon  separate  from 
the  residual  protoplasm.  These  fiagella  are  the  equivalent 
of  spermatozoa  and  are  known  as  microgametes.  They 
enter  the  macrogamete  and  fertilize  it ;  the  fertilized  macro- 
gamete  soon  becomes  motile.  It  is  called  the  travelling 
vermicule  or  ookinet  (motile  egg)  as  it  differs  from  the 
oocyst  (encysted  egg),  formed  by  the  fertilization  of  the 
coccidian  macrogamete,  in  that  it  is  motile  and  not 
encysted.  The  ookinet  passes  into  the  stomach  wall  of 
the  mosquito  and  comes  to  rest  between  the  epithelial 
and  muscular  layers.  It  is  now  known  as  the  zygote, 
is  motionless  and  is  enclosed  in  a  cyst  wall.  Growth 
takes  place,  the  cell  contents  of  the  zygote  divide  into 
several  masses — zygotomeres — from  the  outer  part  of 
which  innumerable  thread-like  bodies  the  zygotoblasts, 
or  sporozoites,  are  formed.  The  cyst  when  fully 
mature  is  distended  with  these  sporozoites  and  ulti- 
mately ruptures,  discharging  the  motile  sporozoites  into 
the  body  cavity  of  the  mosquito.  These  sporozoites 
accumulate  in  the  secreting  cells  of  the  salivary  glands. 
When  a  mosquito  thus  infected  bites  man,  the  sporozoites 
are  injected  into  the  wound  through  the  proboscis.  The 
sporozoites  thus  again  reach  their  warm-blooded  host  and 
pass  into  the  red  corpuscles.  This  sexual  phase  is  carried 
on  entirely  in  the  mosquito,  the  asexual  phase  entirely 


TROPICAL   MEDICINE   AND    HYGIENE 


in  man,  and  the  organism  of  malaria  is  therefore  parasitic 
in  all  stages  of  its  development  (fig,  2.) 

The  names  given  to  the  parasites  in  various  stages  are 
numerous,  and  a  few  only  are  selected  as  those  in  most 
common  use.  The  table  appended  gives  the  terms 
commonly  used  : — 

The  term  alternate  host  is  used  when  it  is  not  meant 
to  indicate  which  cycle,  sexual  or  asexual,  is  carried  on 
in  that  host. 


^"CI 


Fig.  2. — Development  of  malarial  parasite.     The  exogenous  cycle  requires 
an  alternative  host — a  mosquito. 

Intermediate  and  definitive  hosts  are  more  precise 
terms.  The  definitive  host  is  the  host  in  which  the 
sexual  processes  of  multiplication  or  reproduction  are 
carried  out.  In  the  case  of  the  parasites  of  malaria  the 
definitive  host  is  the  mosquito. 

Intermediate  hosts  are  those  in  which  the  asexual 
method  of  multiplication  is  carried  out ;  e.g.,  man  is  the 
intermediate  host  of  the  malaria  parasite. 


INTKODUCTORY  9 

Insects  or  other  alternate  hosts  are  not  required  for 
the  propagation  of  all  the  various  protozoa  which  cause 
disease,  as  in  some,  such  as  the  coccidia  and  AuucJxl 
coll,  part  of  the  development  takes  place  in  earth  (jr 
in  water  without  an  alternative  host. 

Invertebrate  hosts  :  The  commonest  alternative  hosts, 
either  intermediate  or  delinitive,  are  insects,  but  some  of 
the  ticks,  ixodince  and  argasinae,  may  also  serve  as  hosts. 


Table   showing   Comparative  and  Equivalent  Terms  used  in  the 
Description  of  the  Stages  in  'ihe  Development  of  Protozoa. 


Scientific  terms 


Schizogony 
Schizont... 
Merozoite  (spore) 

Gameiocyte 


Microgameie 


Macrogamete 
Sp07-ogony 
Ookinet  ... 

Oocyst     . . . 


Sporoblast 
Sporozoite 


Description 


The  asexual  or  endogenous  cycle  ... 
The  parasite  of  the  asexual  cycle  ... 
The  young  parasites  resulting  from 

asexual  division 
The  potentially  sexual  forms,  male 

and  female 

The  fertilizing  element  or  elements, 
"spermatozoa"  discharged  from 
the  male  gametocyte 
The  female  sexual  form 
The  sexual  or  exogenous  cycle 
The  motile   fertilized  macrogamete 
The    non-motile    fertilized    macro- 
gamete, applied  whether  origin- 
ally motile  or  not 
The  primary  division  of  the  proto- 
plasm of  the  oocyst  (zygote) 
The    final    product   of    the   sexual 
development     formed    from    the 
sporoblasts  or  blastophores 


Terms  commonly  used  in 
descriljing  the  develop- 
ment of  the  parasites 
of  malaria 


Cycle  in  man. 

Sporocytes. 

Spores. 

Gametocyte.    "  Cres- 
cents "    in    subter- 
tian  malaria 

Flageilum   or  micro- 
gamete. 

Macrogamete. 
Cycle  in  mosquito. 
Travelling  vermicule. 

Zygote. 


Blastophore. 

Zygotoblasts,    blasts, 
or  sporozoites. 


Insects  are  infected  with  animal  parasites  in  various 
ways  : — 

(i)  The  blood-sucking  nisects  draw  up  with  the 
blood  any  small  parasites  present  in  that  fluid,  such  as 
the  parasites  of  malaria.  These  parasites  developing  in  the 
insect  host  are  ultimately  injected  into  a  warm-blooded 
host — man  in  this  instance — and  multiply  in  that  host. 

(2)  In  other  cases,  as  in  the  development  of  piro- 
plasmata  and  the  spirochasta  in   ticks,  the  development 


lO  TROPICAL   MEDICINE   AND   HYGIENE 

of  the  parasites  taken  up  with  the  blood  is  continued  in 
the  eggs  of  the  host,  and  the  full  development  does  not 
take  place  till  the  eggs  are  hatched  and  the  young  ticks 
are  sufficiently  developed  to  bite  a  warm-blooded  host, 
when  they  will  transmit  the  infection. 

(3)  The  parasites  drawn  up  with  the  blood  may 
develop  in  the  lumen  or  walls  of  the  alimentary  canal 
and  the  sporozoites  may  be  discharged  with  the  faeces. 

(4)  The  larvae  of  the  invertebrate  host  living  in  water 
become  infected  directly  through  their  food  with  protozoa. 
These  then  develop  and,  as  in  the  case  of  a  monocystis 
described  by  Ross,  multiply  after  encystment,  so  that 
when  the  insect  has  attained  its  perfect  form  —  the 
imago — it  harbours  very  numerous  parasites  which  are 
deposited  with  the  excrement  and  then  live  an  indepen- 
dent existence  till  they  re-enter  other  larvae.  It  is 
possible  that  many  of  the  flagellata  are  thus  transmitted. 

Protozoa  are  not  the  only  parasites  for  which  inverte- 
brates act  as  hosts.  Several  of  the  metazoa  are  conveyed 
in  a  similar  manner.  Bacteria  also  can  be  conveyed  by 
such  hosts.  In  some  instances  the  insects  merely  act 
as  mechanical  carriers.  Thus  the  ordinary  house-fly 
may,  after  alighting  on  the  excreta  of  a  typhoid  patient, 
carry  the  bacilli  to  human  food,  such  as  milk,  directly. 
In  other  instances,  blood-sucking  insects  take  up  bacteria, 
such  as  those  of  plague  and  leprosy,  and  may,  in  the 
former  case  at  least,  infect  other  animals. 

The  bacteria  present  in  the  water  in  which  larvae  live 
are  taken  up  by  such  larvae,  and  in  some  instances,  e.g., 
Bacillus  pyocyanetis,  the  bacteria  continue  to  live  during 
the  various  stages  of  development  of  the  larvae  and  may 
be  widely  distributed  by  the  adult  insect  or  imago. 
The  conveyance  of  vegetable  organisms  by  insects  will 
be  more  fully  considered  in  Part  III. 

Origin  of  Parasites. 

The  question  is  sometimes  raised  as  to  the  origin 
of   parasites,  and   particularly   of  such    parasites   as   are 


INTRODUCTORY 


II 


found  only  in  so  recent  (geoUj^ically)  a  development 
as  man.  No  direct  genealogy  can  be  diawn  up  for  these 
parasites;  they  must  be  derived  from  pre-existing  non- 
parasitic forms  which  gradually  became  parasitic  during 
one,  probably  the  sexual,  cycle,  and  later  parasitic  thr(nigh- 
out  their  entire  cycle.  Possibly,  this  change  first  took 
place  in  birds  or  bats,  and  by  development  from  them 
those  parasites,  which  are  now  parasitic  in  man  only, 
were  developed.  The  intervening  links  are  lost  and  any 
explanation  can  be  merely  hypothetical. 


Protista — Unicellular  organisms. 


Characteristics 
mainly  those 
of  the  veget- 
able king- 
dom, &c. 
Bacteria  to 
be  con- 
sidered, 
Tart  III. 


Protozoa 

Characteristics 
mainly  those 
of  the  animal 
kingdom. 


Sarcodina — 
represe  nted 
by  the  Amaba 
coli. 


Mastigophora  — 
including  Spi- 
rochjet3e,Leish- 
man  -Donovan 
bodies,  Try- 
pa  nosomes, 
Trichomonas 
and  Lamblia 
in  man. 


Sporozoa— 


Telosporidia 


Metazoa 

I 
Animal  Parasites,  Part  II. 


Infusoria — 

represented  in 
man  by  the 
Balantidizini 
coli. 


Neosporidia 


Gregarinida — 

Parasitic  in  earth-worms 
and  many  invertebrata. 
Coccidia :  parasiiic  in 
many  animals,  very 
common  in  rabbits. 
Have  been  observed  in 
man.     Species  (?) 


Sarcosporidia     Myxosporidia. 


Hsemosporidia 


Hcemo- 
gregarinida — 
In  reptiles  and 
few  mammals. 


Babesia  or  Piroplasma —  Hjemamceba — 

Parasitic      in     cattle,     horses,     Including  H.  relicta  (proteosoma) 
sheep,  dogs,  &c.  in  birds  and  at  least  three  species, 

the  cause  of  malaria  in  man. 


12 


CHAPTER   II. 

The  classification  of  the  Sporozoa  is  still  in  dispute, 
and  various  schemes  have  been  propounded  from  time 
to  time.  There  is  no  authoritative  classification  at 
present.  The  scheme  here  given  is  a  useful  one,  but 
is  not  to  be  regarded  as  final  or  as  even  univ^ersally 
accepted. 

Sporozoa. 

(a)  Those  in  which  the  entire  protoplasm,  with  the 
exception  of  dead  residual  masses,  divides  into  spores, 
the  parent  protozoon  disappearing  in  the  process. 

Telosporidia,  e.g.,  parasites  of  malaria,  coccidia,  &c.  In 
this  group  are  included  the  sporozoa  that  cause  the  most 
important  diseases  of  man  and  the  lower  animals — 
malaria,  Texas  fever,  &c. 

The  group  is  variously  divided  by  different  authors  and 
protozoologists.  The  classification  here  given  is  con- 
venient for  the  purpose  :  (i)  Gregarinida ;  (2)  Coccidia; 
(3)  Hcemosporidia ;  (4)  H cemogregarinida. 

(i)  Gregarinida. — The  body  is  of  a  constant  elongated 
form.  They  are  distinguished  by  their  peculiar  creeping 
movements.  They  are  parasitic  in  cells  of  the  intestinal 
walls  of  the  various  invertebrates  during  the  early  part 
of  their  existence,  and  later  are  free  in  the  intestinal 
cavity  or  its  appendages,  where  they  become  encysted, 
and  the  cell  contents  have  been  shown  in  rare  instances 
to  undergo  division  into  spores. 

Reproduction. — Sexual  reproduction  by  the  conjugation 
of  two  cells  which  resemble  each  other. 

(2)  Coccidia. — Of  a  spherical  or  oval  shape,  and  con- 
tained in  definite  cyst  walls  when  mature  ;  only  the 
youngest  forms  are  motile.  Fecundation  by  the  con- 
jugation of  dissimilar  cells.     They  are  parasitic  in   cells 


SPOKOZOA  13 

of  warin-blooclcd  animals  and  invertebrates,  and  fre- 
quently form  massive  tumours.  They  have  been  deseribed 
in  man,  but  little  is  known  at  present  of  human  diseases 
caused  by  them.      Very  common  in  rabbits. 

(3)  Hcvinosporidia  or  Hcvinocylozod. — Parasites  of  the 
red  blood  corpuscles  of  warm-blooded  animals ;  do  not 
form  cysts  in  such  hosts;  are  parasitic  throu-^hout  their 
whole  existence,  the  sexual  phase  taking  place  in  inverte- 
brates, e.g.,  insects  or  ticks.  The  young  forms  have 
active  amoeboid  movement.  They  are  divided  into  two 
main  groups  : — 

{a)  Ha'inamcebcc,  which  form  pigment,  and  usually 
divide  into  a  large  number  of  spores.  The  definitive 
hosts  are  mosquitoes. 


Fig.  3. — Piroplasmata. 

(b)  Piroplasmata  (fig.  3),  which  do  not  form  pigment ; 
divide  into  two  or  more  spores.  Ticks  are  the  definitive 
hosts.  Piroplasmata  have  been  described  in  man,  probably 
erroneously;  common  in  cattle,  sheep,  horses,  dogs,  &c., 
and  usually  lead  to  extensive  blood  destruction,  e.g., 
Texas  fever  in  cattle,  and  hasmoglobinuria  in  sheep  and 
dogs. 

(4)  Hcemogregarinida  are,  by  many  authors,  included 
in  the  Hccmosporidia.  The  young  forms  are  found  in 
red  corpuscles  of  reptiles  (fig.  4),  and  in  few  instances 
in  red  blood  corpuscles  of  mammals,  as  in  the 
Indian  rat  and  the  African  jerboa.  They  may  also  be 
found  in  leucocytes,  as  in  the  dog  and  in  the  palm 
squirrel.  Older  forms  moving  like  gregarines  are  found 
free  in  the  blood  plasma.  Sporulation  takes  place  in  cells 
of  solid  viscera,  such  as  the  liver  and  in  the  bone-marrow. 
It  appears  to  be  doubtful  what  are  the  definitive  hosts  ; 


M 


TROPICAL   MEDICINE   AND    HYGIENE 


in  the  dog  hcemogregarine  they  are  ixodhia.  They  do  not 
form  pigment,  and  differ  from  the  Jicsinosporidia,  in  the 
restricted  sense,  in  the  structure  of  the  nucleus  of  the 
young  parasite.  The  nucleus  stains  with  basic  stain, 
and  the  chromatin  is  distributed  in  fine  granules 
throughout  the  nucleus.  Segmentation  does  not  take 
place  whilst  the  parasites  are  present  in  the  blood.  No 
Jiccniogregarines  are  known  to  occur  in  man,  and  it  is 
only  recently  that  they  have  been  found  in  mammals  and 
birds  (fig.  4  and  Plate  II.) 


Fig.  4. — Haetnogregarines  of  frog. 


(B)  Only  a  portion  of  the  protoplasm  of  the  cell 
divides  into  spores.  The  parent  protozoon  still  remains 
alive,  further  growth  takes  place,  and  again,  part  of  the 
new  protoplasm  divides  into  spores.  This  process, 
repeated  indefinitely  leads  to  the  formation  of  large 
masses  composed  of  spores  enclosed  in  the  much  dis- 
tended parent  cells. 

Neosporidia,  e.g.,  Sarcosporidia. — The  Neosporidia  are 
too  little  studied  to  be  fully  considered  at  present.  They 
are  divided  into  Myxosporidia,  which  occur  in  fishes  and 
in  silkworms,  and  Sarcosporidia,  which  are  very  common 
in  the  muscles  of  domesticated  animals,  and  are  rarely 
found  in  man.  They  are  not  known  to  cause  any  human 
disease. 


15 


CHAPTER  III. 
DISEASES  CAUSED  BY  H^MOSPORIDIA  IN  MAN. 

Malaria. 

(Synonyms  :    Ague,  Fever,   Marsh  Fever,  Puliulisiii, 
Intermittent  Fever,   &c.) 

Malaria  is  the  general  term  applied  to  the  diseases 
caused  by  the  human  haemosporidia  commonly  known 
as  the  parasites  of  malaria.  The  prominent  symptoms 
are  those  of  febrile  disturbance  ;  the  fever  may  be  regu- 
larly periodic,  irregularly  intermittent,  or  remittent,  and 
later  visceral  changes,  especially  enlargement  of  the 
spleen,  and  pigmentation  of  the  spleen  and  liver,  may 
occur.  The  febrile  symptoms  yield  readily  to  treatment 
by  quinine. 

The  parasites  are  conveyed  from  man  to  man  by 
various  species  of  mosquitoes,  belonging  to  the  sub- 
family Anophcllna.  There  are  at  least  three  species  of 
parasites  and  the  symptoms  differ  according  to  the  species 
of  the  parasite  with  which  the  patient  is  infected. 

Geographical  Distribution.  —  Malaria  occurs  in  most 
tropical  and  sub-tropical  countries,  with  the  exception 
of  certain  groups  of  islands,  such  as  the  Seychelles  in 
the  Indian  Ocean,  Fiji,  the  Society  and  Friendly  Islands 
in  the  South  Pacific,  Barbados  and  St.  Helena  in  the 
Atlantic  Oceans.  In  temperate  regions  the  distribution 
is  more  irregular,  and  is  frequently  limited  to  low-lying 
country,  and  the  course  of  rivers  or  their  estuaries. 
Elevation  has  a  decided  effect  in  temperate  regions,  but 
in  equatorial  districts  malaria  may  be  still  common  4,000 
or  5,000  feet  above  the  sea. 

The  topographical  distribution  of  malaria  is  affected  bv 
many  conditions,  such  as  density  of  population,  but  is 


1 6  TROPICAL   MEDICINE   AND   HYGIENE 

mainly  determined  by  the  species  of  mosquito  present, 
and  the  abundance  of  suitable  breeding  places  for  such 
mosquitoes. 

Clinical  Varieties  of  Malaria,  and  Species 
Associated  with  these  Varieties. 

Benign  tertian ;  Tertian  Fever.  Geographical  Distribu- 
tion.— It  occurs  in  all  the  malarial  tropical  countries, 
but  is  rarer  in  Africa  than  in  the  East,  In  sub-tropical 
and  temperate  countries  a  larger  proportion  of  the  cases 
are  benign  tertian  and  it  occurs  further  north  than  the 
other  forms  of  malaria.  It  used  to  be  common  in  some 
parts  of  Great  Britain  and,  rarely,  cases  still  occur. 

The  clinical  course  of  an  attack  of  benign  tertian 
malaria  is  regular,  though  in  a  first  attack  of  a  severe 
type  the  periodicity  may  not  be  well  marked.  The 
attacks  of  pyrexia  are  short,  lasting  some  six  or  eight 
hours.  The  temperature  rises  suddenly,  and  there  is  a 
rigor,  often  so  severe  that  the  bed  on  which  the  patient  is 
lying  is  shaken. 

The  temperature  rises  to  105°  F.  or  more,  and  the 
pulse  is  quick  and  bounding.  The  urine  presents  the 
usual  febrile  characters.  The  skin  is  cold  and  the  features 
pinched,  whilst  the  lips  may  have  a  bluish  tinge. 
Following  the  cold  stage  is  the  hot  stage,  and  during 
this  the  patient  still  has  fever,  usually  high,  severe  head- 
ache, and  the  skin  is  dry.  This  stage  may  last  for  two 
or  three  hours,  and  is  succeeded  by  a  sweating  stage 
during  which  the  temperature  rapidly  falls.  With  the 
onset  of  the  diaphoresis  the  patient  becomes  much  more 
comfortable,  and  the  temperature  rapidly  falls  to  or 
below  normal,  when,  beyond  a  certain  amount  of  debility, 
or  sometimes  a  mild  form  of  collapse,  the  patient  will  feel 
well  and  be  able  to  resume  his  occupation. 

The  next  day,  and  till  forty-eight  hours  after  the 
occurrence  of  the  rigor,  the  patient  remains  to  all 
appearances  in  normal  health.     At  the  end  of  this  period 


DISEASES    CAUSED    I5Y    HA<:M0^P()]<\1)\A    IN    MAN 


17 


there  is  another  siinil;ii"  jiyrexial  attack,  aiul  on  eacli 
alternate  day  in  an  untreated  case  tliese  attacks  of  pyrexia 
recur.  Even  without  active  treatment,  sooner  or  later 
the  paroxysms  diminish  in  severity,  and  gradually  dis- 
appear altogether,  and  the  temperature  may  remain 
normal  or  subnormal  for  two  or  three  weeks,  when 
another  series  of  febrile  paroxysms  on  alternate  days 
will  occur.  These  attacks  of  tertian  fever  alternating 
with  apyrexial  intervals  may  continue  for  two  or  three 
years.  During  the  whole  time  the  patient  is  suffering 
from  infection  with  parasites  of  malaria,  and  visceral 
changes,  especially  enlargement  of  the  spleen,  are  likely 
to  occur,  as  well  as  anaemia  and  general  debility.  Death 
is  unusual  even  if  treatment  be  neglected,  and  in  fatal 
cases  there  is  usually  concomitant  disease. 


TIME 

M 

E 

M 

E    ^ 

1     E 

M 

E   ^ 

n    E 

M 

E 

M 

E 

M 

E 

M 

E 

M 

"e^ 

M 

E 

M 

E 

M 

E 

F° 
105 

104 

103 

1  02 

10  1 

100 

99 

98 

97 

I 

\ 

\ 

' 

t 

1 

, 

\ 

\ 

1 

I. 

N 

\ 

I 

\ 

1 

^ 

V 

"^1 

V 

^i 

V 

V. 

*^ 

i 

^ 

^ 

J 

V 

* 

V. 

-V 

>*- 

y" 

Fig.  5. — Simple  Benign  Tertian. 


In  a  simple  benign  tertian  the  character  of  the  pyrexial 
attacks  and  the  regular  periodicity  of  their  recurrence 
enables  diagnosis  to  be  made  readily.  Blood  examina- 
tion showing  the  presence  of  the  parasites  confirms  this 
diagnosis,  and  it  is  the  only  way  in  which  it  can  be  made 
if  the  patient  is  seen  during  the  apyrexial  attack.  In 
many  cases  of  the  disease  the  fever  is  quotidian,  that 
is,  a  pyrexial  attack  occurs  every  day.  This  is  the  so- 
calied  double  tertian,  and  is  due  to  the  co-existence  of 
2 


15  TROPICAL   MEDICINE   AND   HYGIENE 

two  generations  of  the  parasite  maturing  on  alternate 
days.  Sometimes  the  double  character  of  the  infection  is 
obvious  clinically,  as  the  pyrexial  attacks  vary  in  severity, 
being  alternately  severe  and  mild  (fig.  6).     In  a  double 


TIME 

M     E 

M 

.     M     I 

.     M     f 

:   M   E 

M     E 

M 

E 

M 

E 

M 

E 

105 

I04 

I03 

I02 

lOI 

lOO 

99 

98 

97 

1 

' 

A 

\ 

\  r^ 

[} 

\/ 

0 

V 

V 

'\ 

^ 

r 

^ 

/ 

^r^ 

V 

V 

Fig.  6.— Double  Tertian. 

tertian  the  more  frequent  recurrence  of  the  pyrexia  causes 
more  rapid  development  of  anaemia  and  debility,  and 
the  prognosis  therefore  is  more  serious.  The  nature  of 
the  disease  may  be  suspected  from  the  completeness 
of  the  apyrexial  intervals,  from  the  character  of  the 
pyrexial  attacks,  and  in  some  cases  because  the  pyrexia 
occurs  in  the  morning,  whilst  in  most  forms  of  quotidian 
intermittent  fever,  the  pyrexia  is  in  the  evening.  A  cer- 
tain diagnosis  cannot  be  made  without  an  examination 
of  the  blood. 


7*; 


t;;=: 


■3= 


=3 


ER 


m 


Fig.  7. — Quartan  Fever. 

Quartan  Malaria.  —  Clinically,  this  form  closely  re- 
sembles benign  tertian,  but  differs  from  it  in  that  in  a 
simple  infection  the  pyrexial  attacks  occur  with  an  interval 
of  two  days  between  them   (fig.   7).      The  character  of 


CLINICAL   DIAGNOSIS    IN    MALARIAL    KLVKK' 


9 


each  attack  is  similar  to  that  of  beni.^n  tertian.  Quartan 
malaria  is  less  widely  distributed  than  benign  tertian, 
but  also  occurs  throughout  the  Tropics.  In  some  districts 
cases  are  as  numerous  as  those  of  benign  tertian,  or  even 
more  so.  As  a  rule  in  such  countries  quartan  will  be 
commoner  amongst  the  poorer  classes  and  tertian 
amongst  the  well-to-do,  but  no  race  or  class  is  exempt. 
The  reason  for  the  irregular  distribution  of  quartan  is 
not  known.  Double  and  triple  infections  of  quartan 
malaria  occur,  due  to  two  or  three  generations  of  the 
parasite  being  present  in  the  same  patient,  and  reaching 
maturity  at  intervals  of  twenty-four  hours.  With  three 
generations    the    fever   would    be    quotidian,   with    two 


TIME 

M     E 

M     E 

M     E 

M     E 

M 

e: 

M 

E 

M     E 

M 

E 

F° 
104 

I03 

I  02 

10  1 

1  00 

99 

98 

37 

K 

f, 

^ 

\ 

\ 

\ 

It 

, 

A 

\, 

y 

I 

L 

-,/ 

\ 

N 

J 

\ 

V 

\ 

^ 

V 

Fig.  8. — Double  Quartan. 

generations  there  would  be  fever  on  two  days  and  then 
a  day  free  from  fever,  followed  again  by  two  days 
with  fever  and  so  on  (fig.  8).  The  effects  of  quartan 
malaria  are  very  similar  to  those  of  benign  tertian,  but  it 
is  more  dangerous  to  life,  especially  in  cases  of  dis- 
turbed cardiac  action,  such  as  in  beri-beri.  It  persists  for 
a  longer  time,  and  often  yields  less  readily  to  quinine. 

Clinical  Diagnosis. — The  single  and  double  infections 
are  easy  because  of  the  peculiar  periodicity.  In  a  triple 
infection  the  quotidian  periodicity  may  not  only  be 
confused  with  double  tertian,  but  with  any  diseases  in 
which  quotidian  fever  occurs.  Prognosis  is  good  in 
uncomplicated  cases  if  well  treated. 


20  TROPICAL   MEDICINE   AND    HYGIENE 

Pathology. — The  malaria  parasites  of  both  the  benign 
tertian  and  quartan  fevers  circulate  freely  in  the  blood 
throughout  the  body.  When  the  parasites  are  full-grown 
they  have  a  tendency  to  remain  in  the  splenic  sinuses, 
probably  because  the  red  corpuscles  containing  such 
parasites  are  so  altered  as  to  adhere  to  the  walls  of  the 
smaller  vessels.  This  tendency  is  more  marked  in  benign 
tertian  than  in  quartan,  but  in  both  numerous  full-grown 
forms  will  also  be  present  in  the  peripheral  blood. 

The  rigor  follows  shortly  after  sporulation.  For  some 
unknown  reason,  with  both  species  of  parasites,  the 
stages  of  growth  are  completed  either  all  about  the  same 
time,  or  at  periods  differing  by  twenty-four  hours  from 
each  other,  consequently  parasites  of  intermediate  ages 
are  rarely  met  with.  The  sporulation  of  these  parasites 
leads  to  rupture  of  the  red  corpuscles,  when  the  spores 
together  with  the  remains  of  the  parasites,  pigment,  and 
any  other  products  are  set  free  in  the  plasma. 

The  simplest  explanation  of  the  observed  clinical 
phenomena  is  that  amongst  these  varied  products  are 
(i)  toxins  that  act  on  the  heat-controlling  centre,  and 
(2)  hjemolytic  toxins,  variable  in  amount ;  and  (3)  toxins 
affecting  innervation.  Blood  serum  taken  before  a  rigor 
and  passed  through  a  Berkefeld  filter  will,  when  injected 
into  a  healthy  man,  cause  a  febrile  paroxysm  similar  to 
that  which  occurs  in  malaria.  Of  the  bodies  set  free, 
the  spores  rapidly  enter  other  red  corpuscles,  and  recom- 
mence the  cycle,  or  failing  to  do  this  are  destroyed  by 
phagocytes  or  by  the  blood  plasma,  and  this  destruction 
IS  facilitated  by  the  action  of  quinine.  The  pigment  is 
taken  up  by  the  leucocytes,  usually  by  the  large  mono- 
nuclear or  hyaline  cells,  and  ultimately  deposited  in  the 
spleen,  which  becomes,  in  a  chronic  case,  of  a  deep 
slate  black  colour.  It  is  also  deposited  in  the  connective 
tissue  cells  of  the  liver.  In  an  earlier  stage  the  spleen 
may  merely  appear  to  be  congested,  but  on  microscopic 
examination  abundant  deposits  of  pigment  will  be  seen 
even  then. 


TREATMENT    IN    MALARIAL    FliVli\i  21 

TreaUncnl. — Quinine  in  any  form  and  in  moderate 
doses  will  rapidly  relieve  the  symptoms,  but  to  pievent 
relapses  must  be  continued  in  diminished  doses  for 
months.  Tiie  patient  should  be  kept  in  bed,  not  only 
during  the  pyrexial  period,  but  in  the  intervals,  for  t\V(j 
or  three  days  after  a  pyrexial  attack.  Quinine  is  far  more 
effective  in  a  person  kept  at  a  uniform  temperature  in 
bed  and  on  light  diet.  The  bowels  must  be  kept  open. 
Simple  rest  and  diet  will  often,  without  any  medicine, 
cause  temporary  disappearance  of  the  symptoms. 


22 


CHAPTER    IV. 

SUBTERTIAN  MALARIAL  FEVER. 

Malignant  tertian,  subtertian,  aestivo-autumnal,  and 
tropical  malaria  are  some  of  the  names  applied  to  the  re- 
maining forms  of  malaria,  viz.,  those  due  to  infection  by 
parasites,  which  pass  the  greater  part  of  their  asexual  stage 
in  the  visceral  capillaries.  Young  forms  and  gametocytes 
are  found  in  the  peripheral  blood.  The  gametocytes  are 
the  sausage-shaped  bodies  known  as  "crescents."  It  is  not 
certain  whether  there  is  more  than  one  species  of  these 
parasites.  The  geographical  distribution  of  this  is  more 
limited  than  of  other  forms  of  malaria.  It  is  the 
commonest  form  in  the  Tropics,  and  was  called  by  Koch 
tropical  fever.  In  temperate  regions  it  is  not  found  as 
far  north  as  benign  tertian,  and  in  the  south  of  Europe 
it  occurs  later  in  the  year  than  other  forms  of  malaria, 
i.e.,  in  the  summer  and  early  autumn,  and  was,  therefore, 
called  by  the  Italians  cestivo-autumnal. 

Clinically  it  has  a  less  regular  and  definite  course  than 
the  other  forms,  and  the  stages  of  the  pyrexial  attack  are 
ill-defined,  whilst  the  periodicity  is  uncertain. 

There  is  a  great  liability  to  sudden  onset  of  pernicious 
symptoms,  often  fatal,  even  in  cases  apparently  not  very 
severe.  Hence  the  name  malignant  tertian.  Sometimes 
before  the  fever  there  are  aching  pains  in  the  back  and 
legs;  these  myalgic  pains  may  become  worse  with  the 
onset  of  the  fever,  or  in  other  cases  disappear, 

,  The  pyrexia  presents  few  diagnostic  characters.  The 
tendency  so  marked  in  tertain  and  quartan  for  the 
parasites  all  to  sporulate  about  the  same  time  is  less 
constant.  Subtertian  parasites  of  all  ages  may  be  found 
at  the  same   time  in   blood   removed   from  the  viscera. 


SUHTERTIAN  MALARIAL  KLVKK 


23 


though  a  majority  may  be  abcjut  tlic  same  age.  The 
pyrexial  attack  following  sporulation  is  therefore  neces- 
sarily less  defined,  as  the  toxin  is  being  formed  during  a 
far  longer  period.  The  cold  stage  is  less  often  marked 
by  a  rigor,  frequently  merely  by  a  feeling  of  chilliness ; 
the  hot  stage  is  prolonged  and  the  sweating  stage  is  often 
intermittent,  consisting  of  a  series  of  attacks  of  dia- 
phoresis with  hot  dry  intervals  ;  the  whole  pyrexial  period 
may  last  for  more  than  twenty-four  hours.  The  interval 
in  such  cases  is  short,  as  the  whole  cycle  of  development 
of  the  parasite  appears  to  be  under  forty-eight  hours 
(figs.  9  and  10). 


TIME 

A.M. 

P.M. 

A.M. 

P.M. 

A.M. 

P.M. 

A.M. 

P.M 

fiy.M. 

PM. 

A.M. 

P.M 

A.M 

P.M. 

A.M, 

P.M. 

a.mJpm.] 

F° 
105 

104 

103 

ro2 
1  01 

too 

99 
98 
97 
96 

K 

^ 

■1, 

) 

\ 

1 

^ 

i 

\ 

v 

\ 

r 

V 

t( 

-1    , 

\, 

J 

V 

\ 

\ 

f 

u 

V, 

V     , 

\ 

1 

V 

/ 

\/ 

y 

\ 

v\ 

V 

\. 

4 

/ 

V 

vv 

J 

V 

V 

l^ 

v 

"h 

If 

Fig.  9. — Subtertian  Malaria  with  definite  Tertian  Periodicity. 

In  other  cases  the  pyrexial  attack  is  still  more  pro- 
longed, and  the  interval  correspondingly  shortened.  Xot 
uncommonly  in  a  severe  attack  there  is  no  interval  during 
which  the  temperature  is  normal,  but  merely  a  remission. 
Such  a  fever  is  therefore  not  intermittent,  but  remittent 
(tig.  11).  Vomiting  is  common  and  may  be  persistent. 
When  exceptionally  severe  and  bilious,  particularly  if  asso- 
ciated with  jaundice,  it  is  often  popularly  called  bilious 
remittent  fever.  Constipation  is  the  rule,  but  there  are 
exceptions.  In  many  of  the  cases  of  this  form  of 
malaria  the  temperature  is  not  high,  sometimes  not 
exceeding  100^  or  loi'^  F.  (tig.  12). 


24  TROPICAL   MEDICINE   AND    HYGIENE 

In  benign  tertian,  in  spite  of  the  severe  attacks  of  fever, 
the  patient  may  be  in  good  health  during  the  intervals. 
In  subtertian  this  is  exceptional.  The  patient  may  be 
able  to  be  up  and  force  himself  to  attend  to  business  or 
pleasure,  but  these  attempts  at  "lighting  the  fever"  are 
responsible  for  many  serious  errors  of  judgment,  as  well 
as  causing  serious  risk  to  the  patient. 

Children  are  said  by  some  to  suffer  little  or  not  at  all, 
and  there  is  a  certain  amount  of  truth  in  this  as  they 
may,  whilst  harbouring  the  parasites,  be  capable  of 
playing  about  and  taking  interest  in  their  surroundings. 
Careful  enquiry,  however,  will  usually  show  that  during 
a  great  part  of  the  day  they  are  listless,  do  not  take  food, 
or  otherwise  show  signs  of  ill-health.  They  have  usually 
a  definite  enlargement  of  the  spleen. 

Labial  herpes  is  common  in  malaria,  but  as  a  rule  does 
not  occur  till  late  in  the  attack,  and  frequently  occurs 
when  the  fever  begins  to  subside. 

The  great  peculiarity  of  subtertian  fever  is  the  liability, 
with  little  or  no  warning,  to  the  so-called  pernicious 
manifestations.  These  are  in  the  main  due  to  blood 
stasis  in  different  organs  of  the  body,  caused  by  the 
numbers  of  red  corpuscles  containing  the  parasites  ad- 
hering to  the  walls  of  the  capillaries,  and  obstructing  the 
circulation  in  that  organ.  This  may  occur  in  any  organ, 
and  the  effects  and  clinical  manifestations  vary  accordingly. 

(i)  When  stasis  of  the  blood  occurs  in  the  capillaries 
of  the  central  nervous  system  the  danger  is  great,  and  a 
large  number  of  deaths  are  due  to  this  condition.  The 
symptoms  vary  in  adults  and  in  children. 

In  adults  the  patient  usually  has  a  flushed  face  and 
appears  to  be  dull  and  stupid  with  slow  speech  and 
uncertain  gait.  In  appearance  and  demeanour  he  is  not 
unlike  a  man  in  the  early  stages  of  intoxication.  This 
stupor  may  pass  off  in  mild  cases,  but  in  others  rapidly 
increases,  and  a  condition  of  coma  supervenes.  There 
are  no  convulsions  in  the  great  majority  of  cases  and  no 
localizing  symptoms.     In  a  fatal  case  the  coma  deepens. 


vSUBTERTIAN    MALAKIAL    KKVER 


25 


Fig.   10. — Subterlian  Malaria.     Periodicity  still  definite. 


TIME 

A.M 

P.  M 

A.M. 

P.M. 

A.M. 

PM 

A   M  |PM 

A.M. 

P.M. 

A  M 

P  M 

A.M 

P.M. 

103 

1  02 

10  I 

1  00 

99 

98 

97 

96 

P 

, 

\. 

M 

r 

1/ 

\ 

n 

\ 

\ 

r 

\ 

V, 

/ 

\ 

n 

fN 

\ 

V 

I 

\ 

/ 

V 

\ 

\       , 

' 

{ 

A 

r 

i 

V 

1 

\ 

\1 

V 

M" 

— r 

11 

l 

Fig.   II. — Subtertian  Malaria.     Periodicity  indefinite. 


TIME 

M 

E 

M 

E 

M 

E 

M 

E 

M 

E 

M 

E 

M 

E 

F° 
104 

1  03 

1  02 

1  0  ) 

1  00 

99 

99 

97 

A 

A 

r 

.'^ 

A 

/ 

\ 

/ 

s 

V 

^ 

V 

V 

V 

V 

/^ 

V 

Fig.  12. — Subtertian  Malaria  (un- 
treated). Slight  fever  only.  No  definite 
periodicity.  Diagnosis  based  on  blood 
examination. 


TIME 

A.M. 

P.M 

A.M 

PM 

A.M. 

P.M. 

A.M 

P.M. 

F° 
t06 

105 
1  0^ 

1  03 

102 

1  0  1 

1  00 

99 

96 

97 

A, 

1 

\ 

V 

/ 

\ 

1 

J 

/ 

\         \ 

V 

V 

\       \ 

y 

\     1 

\ 

\ 

1  \ 

1 

i     Y 

"^.A 

W 

Fig,    13.  —  Severe    Subtertian 
Malaria  (treated). 


20  TROPICAL   MEDICINE   AND    HYGIENE 

the  breathing  becomes  stertorous  and  the  conjunctivae 
insensitive.  Even  at  this  stage  recovery  may  occur  with 
energetic  treatment,  or  rarely  even  without  it.  Recovery 
when  it  occurs  is  rapid  and  complete,  the  patient  in 
twenty-four  hours  may  appear  to  be  in  fair  health. 
There  is  no  more  striking  instance  of  the  effects  of 
vigorous  treatment  than  in  a  case  of  this  kind. 

If  untreated  and  the  patient  recovers,  the  attack  usually 
recurs  and  is  then  fatal ;  very  rarely  does  he  survive  two 
attacks  at  short  intervals  without  antimalarial  treatment. 

In  children  the  onset  is  less  gradual,  usually  the  first 
thing  noticed  is  a  convulsion.  When  this  has  occured 
other  convulsions  rapidly  follow,  the  child  remains  coma- 
tose between  the  convulsions,  and  death  occurs  in  four 
to  twelve  hours  from  the  first  attack. 

Even  when  the  convulsions  have  continued  for  two  or 
three  hours,  recovery  is  the  rule  with  energetic  treatment, 
and  is  complete. 

Such  convulsions  are  the  usual  evidence  of  cerebral 
malaria  up  to  the  fifth  year  of  life.  After  this  period 
coma  without  convulsions  begins  to  be  more  common, 
and  after  the  tenth  year  convulsions  are  highly  excep- 
tional. Epistaxis  is  common.  In  these  cerebral  cases 
the  temperature  may  be  little  raised,  or  temperature  up 
to  105°  F.  may  be  noted.  Hyperpyrexia  is  said  occa- 
sionally to  occur. 

(2)  The  lungs  may  be  a  preferential  site,  and  there  is 
increased  rapidity  of  breathing.  Provided  that  the  con- 
dition of  the  heart  and  lungs  is  sound  there  is  compara- 
tively little  danger.  The  congestion  of  the  lungs  induced, 
though  it  may  give  rise  to  suspicion  of  pneumonia,  does 
not  seem  to  be  serious  in  itself.  In  any  condition  of 
cardiac  disease,  or  in  pulmonary  conditions  such  as 
emphysema  and  bronchitis,  the  danger  is  greater,  as  the 
effect  of  such  diseases  is  aggravated.  In  cases  of  tuber- 
culosis there  is  often  haemoptysis. 

(3)  If  the  abdominal  viscera,  and  particularly  the 
intestinal  capillaries  are  blocked,  the  congestion  induced 


SUIiTEKTIAN    MALAKMAI.    I<I':VKR 


27 


in;iy  lead  to  a  condition  of  collapse — the  al^ide  form  of 
malaria.  In  such  cases  the  congestion  of  a  pait  ov  Hie 
whole  of  the  intestinal  wall  may  be  sufiicient  for  iKcmor- 
rliage  to  take  place  into  the  lumen  of  the  alimentary 
canal,  and  h;ematemesis,  mehena,  or  h;emon"hage  from 
the  rectum  may  i-esult,  according  to  the  poilion  of  the 
alimentary  canal  involved.     Occasionally,  with  or  without 


Fig.  14. — Parasites  in  Capillaries  of  Pancreas. 


such  haemorrhage,  the  nutrition  of  the  superiicial  lavers 
of  the  mucosa  is  sufficiently  impaired  to  render  this  mem- 
brane vulnerable  to  the  vegetable  organisms,  bacilli 
and  cocci,  present  in  the  alimentary  canal.  In  that  case 
extensive  superficial  necrosis  occurs  and  ulceration  mav 
result,  which  will  of  course  persist  after  the  malarial  attack 
has  been  relieved  or  has  passed  oft.     (Figs.  14  and  15.) 


^8  TROPICAL   MEDICINE   AND   HYGIENE 

(4)  The  capillaries  in  the  heart  may  contain  blood  in 
a  similar  condition  of  stasis.  This  is  probably  one  of 
the  causes  of  the  cardiac  failure  that  frequently  occurs 
in  malaria.  Persons  with  old  organic  cardiac  mischief, 
pericardial  adhesions,  or  fatty  degeneration  of  the  heart 
should,  therefore,  not  be  exposed  to  the  risk  of  acquiring 
malaria.  The  mortality  from  malaria  in  chronic  alcoholic 
subjects,  and  in  persons  with  beri-beri,  is  probably  due 
to  this  stasis  in  cardiac  capillaries  in  part,  but  may  occur 
with  quartan  malaria,  especially  in  cases  of  beri-beri,  and 
so  may  be  due  to  a  direct  toxic  effect  on  the  cardiac  nerves. 

(5)  The  blood-pressure  is  usually  raised  as  a  result 
of  such  stasis,  and  actual  haemorrhages  are  not  infrequent 
and  may  occur  in  any  part  of  the   body.     Where  there 


Fig.  15. — Parasites  in  Capillary  from  Intestine. 

is  old  atheroma  in  the  cerebral  vessels,  fatal  cerebral 
haemorrhage  may  occur.  Albuminuria  in  some  places 
is  common  during  a  febrile  attack ;  in  other  places  it  is 
unusual.  In  children  nephritis  is  a  common  sequela,  but 
in  adults  it  is  rare  ;  this  nephritis  is  sometimes  fatal.  In 
many  malarious  countries  this  sequela  is  not  met  with. 
Haemoglobinuria,  and  its  possible  relationship  to  malaria 
will  be  considered  under  blackwater  fever.  Glycosuria 
may  occur  during  the  febrile  attacks  but  is  rare.  Neuritis, 
peripheral  and  multiple,  is  often  described,  but  in  most 
instances  it  is  more  probably  due  to  alcohol,  arsenic, 
and    sometimes   to  beri-beri ;   as  a  rare  sequela    it   does 


SUBTERTIAN    MALARIyVF.    I<'KV1':R  29 

occur,  and  then  rapid  improvement  takes  place  with 
quinine  treatment.  Still  more  rarely  paraplegia  may 
follow  an  acute  cerebro-spinal  attack.  Neuralgia  is  often 
attributed  to  malaria,  and  migraine  has  been  ascribed 
to  the  same  cause,  but  there  is  little  evidence  that  there 
is  any  connexion  between  these  diseases  and  malaiia. 
Attacks  not  unlike  "  petit  mal "  may  occur  with  malaria, 
and  may  recur  as  long  as  the  malarial  infection  persists, 
but  they  are  rare. 

Repeated  congestion  may  be  in  part  the  cause  of  the 
chronic  enlargement  of  the  spleen,  of  some  of  the  fibrotic 
changes  in  the  liver  and  other  organs,  and  of  the  tendency 
of  pregnant  women  to  abort,  but  the  influence  of  toxins 
in  inducing  these  conditions  cannot  be  excluded. 

(6)  The  mechanical  effects  due  to  the  temporary  blood 
stasis  caused  by  the  capillaries  of  one  or  two  or  more 
organs  being  blocked  by  corpuscles  containing  parasites 
are  mainly  a  combination  of  the  effects  in  each  organ,  but 
in  such  cases  extra  work  is  always  thrown  on  the  heart, 
and  cardiac  failure  may  be  the  result.  The  immediate 
effects  of  this  condition  have  been  considered  ;  they  con- 
stitute the  main  danger  to  life  in  this  disease.  Sequelae 
of  the  condition  are  not  so  common,  though  even  tem- 
porary impairment  of  the  nutrition  of  certain  parts  of  the 
body,  rendering  the  tissues  more  vulnerable,  may  lead 
to  chronic  changes.  The  frequency  with  which  tuber- 
culosis in  the  West  Indies  dates  from  attacks  of  malarial 
fever  may  be  taken  as  an  instance. 

The  blood  changes,  according  to  Newham,  do  not  as 
a  rule  affect  the  opsonic  index,  and  therefore  do  not  in 
themselves  render  the  person  more  susceptible  to  bacterial 
diseases.  In  subtertian  malaria,  as  in  other  forms  of 
malaria,  the  effects  of  toxins  must  be  considered  as  well 
as  the  effects  of  the  blood  stasis,  peculiar  to  subtertian 
malaria;  the  effect  of  the  substances — toxins — liberated 
when  the  red  corpuscles  containing"  the  parasites  break 
up.  This  happens  irregularly,  more  or  less  continuously, 
but  wdth  a  tendency  for  a  considerable  proportion  of  the 


-30  TROPICAL   MEDICINE   AND   HYGIENE 

parasites  to  be  fully  developed  and  therefore  to  rupture 
the  corpuscles  which  contain  them  about  the  same  time. 
The  toxic  effects,  as  instanced  by  the  pyrexia  and 
vomiting,  tend  therefore  to  show  slight  periodicity. 
Other  evidence  of  toxaemia,  such  as  haemolysis,  is 
variable.  In  some  cases,  even  when  the  fever  is  high, 
there  is  little  or  no  haemolysis,  in  others  it  is  marked. 
When  the  infection  has  continued  for  a  long  time  there 
is  always  anaemia,  but  not  necessarily  severe  anaemia. 
Of  probable  toxic  causation  are  certain  further  symptoms 
which  are  more  common  in  some  places  than  in  others, 
though  morphologically  the  parasites  in  the  different 
places  are  indistinguishable.  These  include  (a)  Albu- 
minuria, which  may  be  transient,  appearing  and  dis- 
appearing with  each  attack  of  fever,  or  occurring  much 
as  it  does  in  scarlet  fever,  as  a  definite  sequela  of  the 
disease,  (b)  Neuritis,  which  may  be  general  or  may  occur 
mainly  in  the  legs,  and  lead  to  a  paresis  with  loss  of 
knee-jerks,  muscular  tenderness  and  rapid  wasting  of 
the  muscles.  In  some  of  these  cases  there  is  some 
disturbance  of  the  higher  cerebral  functions,  such  as 
loss  of  memory.  These  cases  are  often  confounded  with 
alcoholism,  and  may  be  associated  with  it.  Rapid  im- 
provement takes  place  under  quinine. 

Diagnosis. — On  the  clinicial  symptoms  alone,  even 
during  the  stage  of  pernicious  attacks,  certain  diagnosis 
is  impossible ;  suspicion  only  is  warranted.  Certainty 
one  way  or  the  other  is  essential,  as  for  any  case 
persistent  treatment,  and  for  severe  cases  energetic 
treatment,  is  necessary.  It  is  also  essential  that  the 
possibility  of  malaria  should  be  excluded  in  many  cases, 
as  without  this  time  will  be  wasted  before  the  real 
disease,  possibly  tractable,  is  diagnosed.  The  only 
satisfactory  method  is  by  blood  examination.  With 
well-made  films,  either  fresh,  or  preferably  stained  by 
Leishman's  method,  the  parasites  can  be  found  usually 
with  little  difiiculty.  The  essential  is  that  the  films, 
whether  wet  or  dry,  are  so   spread  that  in  considerable 


PROGNOSIS    IN    MALARIAL    FKVER  3I 

portions  of  the  liliii  the  corpuscles  are  lyin^^  Hat  and 
separate  from  one  another. 

The  evidences  of  malai'ia  derived  from  blood  examina- 
tions are  : — 

(i)  Discovery  of  parasites.  This  is  conclusive,  but 
in  persons  who  have  been  takini^  quinine  the  non- 
discovery  does  not  prove  that  the  patient  has  not  got 
malaria.  In  the  intervals  between  attacks  of  fever, 
whether  after  treatment  or  naturally,  a  prolonged  search 
may  be  necessary  before  the  parasites  are  found. 

(2)  Pigmented  leucocytes,  usually  the  large  mono- 
nuclear or  hyaline  leucocytes.  These  are  conclusive  of 
recent  malaria.  They  are  often  very  scanty,  so  that  it  is 
only  rarely  that  they  aid  in  the  diagnosis  unless  a  pro- 
longed search  be  made. 

(3)  Increase  in  the  relative  proportion  of  the  large 
mononuclear  leucocytes,  without  any  increase  in  the 
total  number  of  leucocytes.  In  malaria  and  after  malaria, 
for  a  variable  period  but  sometimes  for  quite  six  months, 
the  proportion  of  large  mononuclear  leucocytes  is  raised 
to  15  per  cent,  or  much  more.  This  change  is  not 
affected  by  the  administration  of  quinine,  and  is  more 
marked  when  there  is  no  pyrexia.  It  is  therefore  of 
great  value  in  just  those  cases  of  malaria  in  which  the 
parasites  are  not  to  be  found.  It  does  not,  however, 
prove  that  the  malaria  is  still  present,  as  the  change  is 
so  persistent,  but,  as  a  rule,  it  indicates  past  malaria. 
If  there  is  a  coexisting  disease  such  as  pneumonia,  sepsis, 
or  even  acute  hepatitis,  which  produces  an  increase  in 
the  number  of  polymorphonuclear  leucocytes,  this  change 
will  completely  mask  the  mononuclear  increase  of 
malaria  in  a  differential  count.  In  children  it  is  of  less 
value  as  in  them  an  increase  in  the  large  mononuclear 
leucocytes  is  fairly  common  without  any  disease. 

Prognosis. — Is  good,  but  energetic  treatment  may  be 
required,  and  relapses  will  generally  occur  unless  the 
treatment  be  prolonged  for  months  after  the  last  onset 
of  a  febrile  attack.     When  pernicious  symptoms  super- 


.32  TROPICAL   MEDICINE   AND   HYGIENE 

vene  there  is  great  danger,  and,  unless  these  can  be 
speedily  controlled,  death  will  occur.  If  the  recognition 
of  the  nature  of  the  disease  is  made  early  the  patient  will 
usually  be  saved. 

The  case  mortality  among  hospital  patients  is  small, 
and  also  in  private,  but  the  number  of  deaths  due  to 
malaria  untreated  or  inefficiently  treated  is  large,  but 
impossible  to  calculate.  The  high  mortality  in  the 
Tropics,  India,  Africa,  &c.,  is  largely  attributable  to  fever, 
both  amongst  Europeans  and  natives,  and  is  the  cause 
of  the  high  infantile  mortality  from  convulsions. 

The  prognosis  is  much  less  favourable  when  malaria 
occurs  in  persons  suffering  from  other  diseases.  Organic 
cardiac  disease,  and  diseases  such  as  beri-beri  or  chronic 
alcoholism,  which  affect  the  innervation  of  the  heart, 
render  the  prognosis  less  favourable.  When  there  is 
atheroma  of  the  cerebral  vessels,  fatal  cerebral  haemor- 
rhage may  occur.  Syphilis  in  a  person  with  malaria 
will  not  yield  to  antisyphilitic  treatment  till  the  malaria 
is  treated. 

Pathological  Anatomy. — The  general  appearances  may 
be  inferred  from  the  symptoms,  in  an  acute  case  there 
is  always  congestion  of  some  of  the  organs,  and  in  those 
in  which  blood  stasis  has  occurred  this  may  be  extreme. 
Parasites  will  be  found  in  the  cells  in  the  capillaries  or, 
if  the  examination  is  too  long  after  death,  pigment  from 
the  breaking  down  of  these  parasites.  Cloudy  swelling 
of  the  cells  of  the  liver  and  kidneys  is  usually  present. 

The  special  changes  consist  of  the  deposits  of  malarial 
pigment  in  the  connective  tissue  cells  of  the  liver  and  in 
the  parenchymatous  cells  of  the  spleen. 

This  pigment  is  fine  and  intracellular  when  derived 
from  recent  malarial  infection,  and  intravascular  when 
parasites  are  present.  It  is  much  coarser  and  not 
obviously  intracellular  when  derived  from  an  old  infec- 
tion. In  cases  where  haemolysis  has  been  great,  haemo- 
siderin  may  be  found  abundantly  in  the  hepatic  cells,  in 
cells  in  the  convoluted  tubules  of  the  kidneys  and  some- 


PATHOLOGICAL   ANATOMY    IN    MALAI^IAL    FLVLR         33 

times  in  the  spleen.  Granules  j^iving  the  reactions  of 
iron  in  its  inorganic  combination  may  also  be  present. 

Haemorrhages  are  exceptional.  The  lymphatic  glands 
are  sometimes  enlarged,  and  rarely  Peyer's  patches. 
More  commonly  the  Malpigliian  bodies  in  the  spleen  are 
enlarged  and,  as  diey  are  not  pigmented,  stand  out 
boldly  as  white  spots  against  the  blackish  background  of 
the  parenchyma. 

Decomposition  is  not  usually  rapid,  but  the  parasites 
die  shortly  after  the  death  of  their  host.  Blackening  of 
organs  from  decomposition  must  not  be  mistaken  for 
malarial  pigmentatio.n.  If  the  examination  be  made 
shortly  after  death  the  spleen  is  always  firm,  but  when 
the  rigor  mortis  of  the  tissues  has  passed  off,  an  event 
that  occurs  earlier  than  the  disappearance  of  rigor  mortis 
of  the  voluntary  muscles,  it  is  softer  and  more  flaccid, 
but  only  becomes  diffluent  in  the  early  stages  of 
putrefaction. 

Accumulations  of  parasites  are  found  in  the  capillaries 
in  various  organs  ;  even  in  the  same  case  they  may  be 
found  in  many  organs,  less  commonly  they  may  be  found 
only  in  the  capillaries  of  one  organ. 

In  fatal  cases  the  capillaries  of  the  brain,  heart,  intes- 
tines and  other  abdominal  viscera  are  thus  affected  most 
frequently,  but  in  other  organs,  such  as  the  lungs,  the 
capillaries  may  be  found  in  the  same  condition. 

Whatever  organ  is  involved  is  markedly  congested,  and 
sometimes  is  of  a  dull  slaty  colour  from  the  pigment 
contained  in  the  parasites  or  in  the  cells  in  the  parenchyma. 

The  spleen  is  always  engorged  and  tumid,  and  this  is 
shown  by  the  tense  smooth  capsule  free  from  wrinkles 
and  the  broad  rounded  edge  of  the  organ.  It  is  not 
necessarily  much  above  the  avei"age  weight  when  death 
occurs  early  in  the  course  of  the  disease,  and  then  it 
usually  weighs  10  to  15  oz.  or  more  in  an  adult. 

Examined  microscopicallv  malarial  pigment  is  always 
found,  but  in  early  cases  the  spleen  to  the  naked  eye 
may  appear  red ;  the  dense  black  colour  sometimes  seen 

3 


34 


TROPICAL   MEDICINE   AND   HYGIENE 


is  found  in  chronic  cases,  and  may  be  only  the  remnant 
of  malaria  previously  contracted. 

The  liver  also  is  pigmented,  and  the  pigment  is 
deposited  mainly  in  the  cells  between  the  lobules,  so 
much  so  that  in  some  cases  the  outlines  of  the  lobules 
appear  to  be  pencilled  out  in  black. 

Treatment. — Many  drugs  have  been  employed,  quinine, 
methylene  blue,  arsenic,  opium,  &c.,  but  of  these  only 
the  first  two  have  a  decided  effect  on  the  parasites.  Since 
the  general  adoption  of  blood  examination  has  led  to  a 
sure  diagnosis,  the  value  of  quinine  in  malaria  has  been 
fully  confirmed. 

Any  of  the  salts  of  quinine  may  be  used.  The  ethyl 
carbonate,  euquinine,  has  the  great  advantage  of  being 
tasteless,  and  is  used  for  children  and  such  adults  as  have 
great  distaste  for  quinine.  It  is  too  expensive  for  general 
use. 

The  form  in  which  quinine  is  taken  is  of  some  import- 
ance. The  amount  of  anhydrous  quinine  in  the  various 
salts  differs,  and  the  solubility  of  the  salts  also  varies,  as 
shown  in  the  subjoined  table,  which  also  shows  the 
doses  of  the  common  preparations  of  quinine  equivalent 
as  regards  the  amount  of  quinine  to  lo  grains  of  the 
hydrochlorate. 


Percentage 
of 

Solubility 
in 

Equivalent 

alkaloid 

water 

doses 

Quinina 

lOO 

Nil 



Q.  hydrochlorate  ... 

8i-8 

I  in  40 

10  grains 

Q.  bihydrochlorate 

72 

I  in  I 

"•4  „ 

Q.  sulphate 

73*5 

I  in  800 

ii-i   „ 

Q.  bisulphate 

59-x 

I  in  II 

13-8  „ 

Q.  hydrobromate  ... 

76-6 

I  in  45 

10-9  „ 

Q.  bihydrobromate 

60 

I  in  7 

13-6  „ 

Q.  ethyl  carbonate 

81 -8 

Nil 

10      ,, 

With  a  perfectly  healthy  stomach  and  a  free  secretion 
of  hydrochloric  acid,  all  these  salts  will  be  converted  into 
the    hydrochlorate    or    bihydrochlorate    before    they   are 


TREATMENT   IN    MALARIAL   FEVER  35 

dissolved,  so    that  in   tliat  case  the   varyinj^  amounts  of 
quinine  only  are  of  importance. 

When  the  stomach  is  not  healthy  or,  as  is  so  often  tlie 
case  in  malaria,  the  acid  secretion  is  not  normal,  the 
case  is  different  and  at  the  best  the  quinine  will  be  more 
slowly  absorbed,  or  at  the  worst  only  absorbed  in  small 
part.  The  same  occurs  with  an  empty  stomacli  as  then 
there  is  little  or  no  acid  secreted. 

The  acid  set  free  in  the  case  of  the  sulphates  will  be 
sulphuric  acid  which  is  not  of  much  value  in  the 
digestive  processes,  and,  acting  as  an  astringent  may 
increase  the  tendejicy  already  marked  in  malaria  to 
digestive  disturbances. 

When  the  hydrobromate  is  used,  and  still  more  with 
the  bihydrobromate,  the  amount  of  bromine  has  to  be 
considered,  as  in  10  grains  of  bihydrobromate  there  is 
bromide  equivalent  to  about  3  grains  of  potassium 
bromide.  Where  this  drug  is  used  as  a  prophylactic  for 
long  periods,  mental  depression  may  occur  not  only  from 
the  quinine  but  also  from  the  bromine. 

The  hydrochlorate  contains  a  larger  proportion,  81  "8 
per  cent.,  of  quinine  ;  it  is  a  little  more  expensive  but  not 
sufficiently  so  to  prevent  its  general  use.  It  is  more 
soluble  (i  part  in  40  of  water)  and  less  irritating.  The 
bihydrochlorate  contains 72  per  cent,  of  quinine;  it  should 
always  be  used  for  intramuscular  and  intravascular  injec- 
tions as  it  is  soluble  in  one  part  of  water.  It  is  also  best 
for  rectal  injections. 

Quinine  may  be  given  (i)  by  the  mouth  ;  (2)  bv  the 
rectum ;  (3)  by  intramuscular  injection  ;  (4)  by  intra- 
venous injection. 

(i)  By  the  mouth  is  on  the  whole  the  most  convenient 
method,  and  it  suffices  in  the  vast  majority  of  cases. 
The  quinine  should  be  given  ///  solution  dissolved  in 
water  with  the  addition  of  an  acid ;  hvdrochloric  or 
hydrobromic  is  the  best,  but  sulphuric  or  tartaric  acid 
may  be  used.  Lime  juice,  either  fresh  or  preserved, 
sherry   and    other   acid   solutions  may   also    be  used    as 


36  TROPICAL   MEDICINE   AND   HYGIENE 

solvents.  When  given  in  solution  it  is  certainly  and 
rapidly  absorbed,  but  the  taste  to  many  people  is 
nauseating. 

Freshly  made  pills,  made  by  the  addition  to  quinine 
sulphate  or  hydrochlorate  of  a  small  crystal  of  tartaric 
acid  and  a  drop  of  water,  have  no  disadvantage. 

Sugar-coated  pills  or  tablets  or  old  pills  must  not  be 
used,  as  they  are  frequently  passed  undissolved.  Com- 
pressed tablets  are  occasionally,  but  rarely,  passed  in 
this  way  under  ordinary  circumstances.  They  may  be 
used  for  prophylaxis  during  convalescence  and  in  mild 
attacks,  but  should  not  be  relied  upon  in  severe  attacks. 
They  are  convenient  when  travelling  as  they  can  be 
readily  broken  up  and  dissolved  if  required.  Before 
using  tablets  in  cases  of  fever,  typhoid  fever  must  be 
excluded.  Fatal  haemorrhage  has  occurred  in  cases  of 
typhoid  where  quinine  tablets  have  been  given.  Quinine 
is  sometimes  taken  in  cigarette  papers,  but  it  is  not  certain 
that  taken  in  this  way  the  quinine  will  be  absorbed. 

(2)  Administration  by  the  rectum  results  in  very  rapid 
absorption.  It  is  particularly  useful  when  there  is  much 
vomiting  and  when  it  is  desired  to  give  frequent  large 
doses,  as  in  comatose  cases  or  in  children  with  con- 
vulsions when  it  is  necessary  that  large  doses  should  be 
absorbed,  and  that  these  doses  should  be  repeated  at 
short  intervals. 

The  hydrochlorate,  dissolved  in  the  minimum  amount 
of  acid  and  freely  diluted  should  be  used. 

The  injection  must  be  given  warm,  and  with  a  fairly 
long  tube  to  be  sure  that  it  is  retained. 

In  children  it  is  necessary  for  the  nurse  to  keep  the 
buttocks  pressed  together  to  ensure  the  retention  of 
the  quinine  solution  till  it  is  absorbed.  Irritation  and 
inflammation  of  the  rectum  are  said  to  follow  this 
method  of  administration,  when  the  sulphate  dissolved 
in  sulphuric  acid  is  given,  but  even  then  these  results 
are  exceptional. 

(3)  Intramuscular  injection  has  many  advocates.     The 


TREATMENT    IN   MALARIAL    FLVKR  37 

results  are  good  but  no  better,  even  if  as  good,  in 
comatose  cases  than  rectal  injections.  It  is  assumed 
that  absorption  is  rapid.  The  quinine  is,  however,  preci- 
pitated in  the  muscle,  and  is  gradually  absorbed,  the 
great  advantage  of  its  administration  is  that  it  is  being 
continuously  absorbed.  It  is  particularly  useful  in 
persons  with  chronic  dyspepsia  or  gastric  irritability,  and 
a  comparatively  small  dose  of  quinine  is  required. 

Precautions. — Unless  antiseptic  precautions  are  adopted 
there  is  danger  of  tetanus  or  formation  of  abscesses,  and 
the  injection  must  be  made  into  a  large  muscle. 

(4)  Intravenous  injections  are  used  in  pernicious  cases 
by  some  ;  it  is  doubtful  if  the  results  are  better  than 
those  obtained  by  rectal  injection. 

Dosage. — This  is  most  important.  It  may  be  stated 
with  confidence  that,  where  the  diagnosis  is  verified  by 
blood  examination,  treatment  with  quinine  never  fails  if 
the  doses  be  sufficient  and  there  is  time  for  the  drug 
to  act. 

In  many  cases  small  doses  will  suffice  ;  even  the  amount 
of  quinine  contained  in  a  drachm  of  Easton's  syrup  may 
bring  the  temperature  down  to  normal.  Ten  to  fifteen 
grains  of  any  of  the  salts  of  quinine  daily  will  usually 
suffice  for  benign  tertian  and  quartan,  and  sometimes 
for  subtertian.  It  is  more  uniformly  satisfactory  to  give 
30  grains  daily  till  the  fever  is  down  and  then  reduce  the 
amount.  Where  it  is  absolutely  necessary  to  economize 
the  quinine,  it  will  be  better  to  give  a  single  dose  before 
an  expected  rigor,  as  a  smaller  dose  will  then  suffice 
to  relieve  the  pyrexia. 

In  severe  cases  with  pernicious  symptoms  no  time 
should  be  lost ;  moderate  or  even  large  doses  so  often 
fail,  that  if  life  is  to  be  saved  the  risks  of  quinine  poison- 
ing must  be  faced.  In  such  cases  in  adults  a  single 
dose  of  20  grains  should  be  given  at  once,  preferably 
per  rectiun,  and  repeated  in  an  hour,  and  10  grains  given 
every  hour  till  improvement  takes  place,  usually  a  matter 
of   some   four  or  six  hours.     Even    in    young    children 


38  TROPICAL   MEDICINE   AND   HYGIENE 

5-grain  doses  may  be  given  at  corresponding  intervals 
in  the  same  manner.  If  there  is  any  sign  of  cardiac 
failure,  stimulants,  preferably  alcoholic,  must  be  freely 
administered.  Every  effort  must  be  made  to  keep  the 
patient  alive,  as  recovery  is  certain  if  the  quinine  has 
time  to  act.  Hot  packs  in  adults  and  hot  baths  in 
children  seem  to  be  beneficial. 

The  time  of  giving  quinine  with  reference  to  fever 
is  not  considered  to  be  of  so  much  importance  now  as 
it  was.  The  action  of  the  quinine  is  more  decided  if 
it  is  given  when  the  spores  are  set  free,  and  therefore 
in  benign  tertian  and  quartan  a  small  dose  given  before 
the  rigor  is  more  effective  than  the  same  dose  later. 
It  is  in  the  period  immediately  before  the  onset  of  fever 
that  sporulation  occurs  and,  therefore,  when  quinine  acts 
best  ;  and  there  is  no  advantage  in  reducing  the  tempera- 
ture artificially,  as  by  the  use  of  antipyretics,  before  giving 
the  quinine,  except  that  vomiting  is  less  likely  to  ensue 
and  the  headache  is  less.  In  all  cases  of  malaria,  treat- 
ment with  quinine  must  be  continued  for  a  long  period 
after  the  disappearance  of  the  symptoms. 

A  commonly  successful  practice  is  to  give  10  grains 
daily  for  one  week,  every  other  day  for  two  weeks,  and 
twice  a  week  for  a  month,  and  15  grains  once  a  week  for 
two  months.  In  the  majority  of  cases,  even  if  large 
doses  of  quinine  have  been  given  during  the  pyrexial 
period,  relapses  will  occur  unless  the  use  of  the  drug  be 
persisted  in. 

In  malaria  there  is  usually  constipation ;  this  should 
be  relieved,  preferably  by  saline  aperients,  but  calomel 
and  calomel  and  jalap  are  used  by  many. 

Antipyretics,  such  as  phenacetin,  are  not  advisable  in 
severe  cases.  In  mild  cases,  if  the  headache  be  severe, 
they  give  relief  and  may  be  harmless. 

Management. — One  of  the  points  that  is  constantly 
arising  in  connexion  with  malaria  is  the  advisability  of 
allowing  the  patient  to  work  during  the  intervals  of  an 
attack  or,  in  the  case  of  subtertian,  when  the  patient  is 


NURSING   IN    MALARIAL   FLVIiR  39 

still  suffering  from  a  low  type  of  fever.  In  both  cases 
recovery  is  delayed  by  any  attempt  at  getting  up,  exposure 
of  any  kind,  or  work,  physical  or  mental. 

In  benign  tertian  and  quartan  fevei"  it  may  be  perniis- 
sible  for  urgent  work  to  be  done  during  the  apyrexial 
interval.  This  should  be  restricted  as  far  as  possible  to 
routine  work.  It  must  always  be  remembei'ed  that  work 
done  under  these  conditions  is  "inferior.  With  the 
subtertian  fever,  even  though  the  temperature  be  nc^rmal 
or  nearly  so,  no  responsible  work  should  be  undertaken 
as  the  patient  is  incapable  of  acting  with  judgment. 
Instances  of  grave  errors  resulting  in  serious  calamities 
are  common.  A  very  decided  stand  has,  therefore,  to  be 
taken  in  these  cases,  as  one  of  the  prominent  symptoms 
is  an  obstinacy  which  leads  the  patient  to  insist  on  doing 
work  when  he  is  mentally  incapable  of  dealing  with  it 
satisfactorily. 

As  regards  residence  in  a  malarial  country  of  a  person 
who  has  suffered  severely,  the  general  condition  has  to 
be  considered,  as  well  as  the  completeness  of  the  recovery. 
There  is  no  reason  why  return  should  not  be  allowed  if 
these  points  are  satisfactory,  as  there  is  no  increased 
liability  to  reinfection.  On  the  contrary,  there  is  a 
variable  amount  of  partial  immunity. 

Nursing. — In  an  ordinary  attack  of  malaria  skilled 
nursing  is  hardly  required  except  for  comfort.  The 
patient,  moreover,  is  often  irritable,  or  may  be  slightly 
delirious,  and  no  unwelcome  attentions  should  be  per- 
sisted in  except  such  as  may  be  absolutely  necessary. 
He  should  be  protected  from  noise,  bright  light,  and 
above  all  from  draughts. 

Blankets  and  clothing  require  changing  after  the  sweat- 
ing stage,  and  both  must  be  thoroughly  dry  and  warm. 

Warm  sponging  after  the  sweating  stage  is  comforting 
and  cleanly. 

During  the  stage  of  rigor  hot  bottles  are  appreciated, 
but  are  not  necessary.  Some  protection  to  the  bed  is 
necessary,  as  the    perspiration  is  frequently  sufficient  to 


40  TROPICAL   MEDICINE   AND   HYGIENE 

soak  through  the  blanket,  and  mattresses  thus  acquire  a 
peculiar  unpleasant,  musty  smell. 

To  protect  the  bed  fine  native  grass  mats  placed  under 
the  blanket  are  serviceable ;  they  are  usually  cheap  and 
can  be  washed  and  sunned.  In  hot  weather  these  mats 
will  be  found  very  cool  and  pleasant  to  lie  on.  Water- 
proof sheets,  such  as  are  used  in  England,  perish  rapidly 
in  the  Tropics  and  are  expensive. 

If  there  is  much  vomiting  smapisms  should  be  applied 
to  the  epigastrium.  Drinks  should  then  be  given  hot, 
and  in  small  quantities  at  a  time. 

In  the  severe  forms  of  fever  more  attention  is  required. 
Any  tendency  to  a  lethargic  condition  must  be  noted, 
as  this  often  precedes  coma  or  hyperpyrexia,  and  the 
temperature  must  be  taken  at  once,  and  every  half  hour 
afterwards,  if  this  tendency  is  observed,  till  the  symptoms 
subside,  even  if  the  temperature  is  very  little  above 
normal. 

If  coma  supervenes,  hot  packs  are  by  many  considered 
to  be  of  great  value.  These  may  be  given  on  the  bed, 
but  the  packs  are  more  readily  and  rapidly  changed  if 
the  bedding  and  patient  are  placed  on  the  floor.  Either 
a  blanket  or  sheet  may  be  used.  The  blanket  retains  the 
heat  longer,  but  the  sheet  is  more  readily  arranged.  The 
sheet  or  blanket  must  be  placed  in  water  of  a  temperature 
ten  degrees  higher  than  the  pack  is  meant  to  be  applied. 
This  is  the  safest  rule,  but  in  emergencies,  or  when  an 
exceedingly  hot  pack  is  required,  it  is  better  to  use  nearly 
•boiling  water  and  wait  until,  as  tested  by  the  elbow,  the 
temperature  is  such  that  it  can  just  be  borne.  This  will 
be  about  104°  to  108"  F. 

Great  care  must  be  taken  to  thoroughly  wring  the 
blanket,  especially  at  the  ends ;  retention  of  hot  water 
in  these  places  frequently  leads  to  blistering  of  the 
patient.  The  patient  should  be  turned  on  to  his  side, 
the  blanket  is  well  wrung  out  and  folded  lengthwise, 
the  edges  must  be  close  to  the  back  of  the  patient, 
towards  the  middle  of  the  bed.     He  is  then   rolled  on 


ADMINISTRATION   OF   QUININE    IN    MAF.ARIAL    FICVICR      41 

his  hack  on  to  the  under  half  of  the  damp,  hot  blanket, 
which  is  folded  round  him  from  head  to  foot,  and 
covered  with  other  and  dry  blankets.  If  profuse  perspira- 
tion does  not  occur,  or  the  temperature  rises,  the  pack 
should  be  repeated.  After  the  pack  is  removed,  wrap 
the  patient  in  a  warm  dry  blanket  and  rub  him  with 
warm  dry  towels.  These  packs  must  be  liot,  and  in 
desperate  cases  and  with  a  patient  deeply  comatose  a 
certain  amount  of  blistering  may  result.  This  is  usually 
due,  not  to  the  excessive  heat,  but  to  imperfect  wringing 
of  the  pack.  When  the  temperature  is  so  high  that 
hyperpyrexia  is  feared,  cold  or  even  iced  baths  may  be 
required.  The  patient  should  be  lowered  in  a  sheet 
into  the  bath  at  a  temperature  of  85°  F.,  an  assistant 
supporting  the  head.  Cold  water  is  gradually  added  and 
well  mixed,  or  ice,  if  available,  may  be  added.  The 
temperature  must  be  taken  frequently,  every  five  minutes 
per  rectum,  as  when  once  it  begins  to  fall,  and  has  fallen 
below  a  point  of  danger,  102°  F.,  it  will  continue  to  fall 
after  removal  of  patient  from  the  bath,  and  dangerous 
or  even  fatal  collapse  may  occur  if  the  temperature  has 
been  too  much  reduced.  Stimulants  are  practically 
always  required.  When  a  bath  is  not  available  cold  or 
iced  packing  is  sometimes  employed.  A  half  pack  is 
very  useful,  and  can  be  managed  single-handed.  The 
patient,  stripped  to  the  hips,  is  placed  on  his  back  on 
a  waterproof  sheet  or  native  mat,  and  large  towels  wrung 
out  of  cold  water  are  placed  on  his  chest  or  abdomen, 
completely  covering  them,  and  tucked  in  at  the  sides. 
These  towels  are  repeatedly  changed  and  renewed  from 
a  bucket  of  cold  water  placed  at  the  bedside.  This 
water  may  be  further  cooled  with  ice,  or  a  block  of 
smooth  ice  may  be  rubbed  up  and  down  over  the  wet 
towel  as  it  lies  on  the  patient,  so  as  to  keep  it  constantly 
cold — "  ice  planing."  Cold  applications,  ice-bags,  &c., 
to  the  head  should  also  be  used. 

Adininistrafion  of  Quinine. — This,  when  given  by   the 
mouth,  may  cause  vomiting.     The  ordinary  precautions 


42  TROPICAL   MEDICINE    AND    HYGIENE 

should  be  taken,  but  if  the  vomiting  is  uncontrollable 
hypodermic  injections  of  morphia,  ^  grain,  should  be 
given,  preferably  over  the  epigastrium.  It  is  absolutely 
necessary  that  quinine  should  be  absorbed,  and  if  it 
cannot  be  readily  retained  by  the  stomach,  it  must  be 
administered  in  some  other  manner.  In  giving  quinine 
by  the  rectum,  the  solution  and  the  nozzle  of  the  syringe 
must  be  warm,  and  a  long  tube  should  be  used  so  that 
the  injection  is  given  well  above  the  anus.  The  injection 
must  be  made  very  slowly. 

The  patient  is  to  be  kept  perfectly  still  and  the  buttocks 
should  be  pressed  together  in  order  to  counteract  any 
slight  efforts  at  straining.  In  children  the  nurse  must 
maintain  this  pressure  for  half  an  hour,  otherwise  the 
injection  will  not  be  retained  sufficiently  long  for  absorp- 
tion to  take  place. 

Superficial  hypodermic  injections  of  quinine  must  not 
be  given.  If  administered  by  injection  the  quinine  must 
be  introduced  into  one  of  the  larger  muscles,  such  as 
the  gluteus  maximus.  Injections  into  the  forearm,  or 
amongst  any  mass  of  small  muscles,  cause  a  good  deal 
of  pain  and  swelling,  and  if  injected  into  or  close  to  a 
nerve  trunk  may  cause  permanent  paralysis.  This 
accident  occurs  most  frequently  if  the  injections  be 
given  in  the  forearm.  The  most  important  point  to 
be  remembered  about  these  injections  is  their  liability 
to  cause  tetanus  or  abscesses.  Such  accidents  appear 
to  be  due  to  the  injury  inflicted  by  the  quinine  upon 
the  tissues  with  which  it  came  in  contact,  thus  facilitating 
the  grow^th  of  any  organism  introduced  with  it.  The 
risk  does  not  occur  where  strict  antiseptic  precautions 
are  taken.  The  skin  at  the  point  of  injection  must  be 
cleaned  and  thoroughly  w^ashed  with  antiseptics,  alcohol 
and  ether,  and  i  in  20  carbolic  acid,  or  better,  2  per 
cent,  lysol.  The  syringe  must  be  sterilized  by  boiling, 
and  the  solution  of  quinine  must  be  sterilized  in  the 
same  way  immediately  before  use. 

Synthetic  antipyretics,  such  as  antipyrin  and  phenacetin. 


DIET    IN    MALARIAL    FEVER  43 

s^ive  relief,  but  should  only  he  used  in  patients  who  ai'e 
in  bed  and  in  mild  cases.  Thev  may  in  severe  cases 
be  the  cause  of  fatal  collapse.  On  the  whole  their  use 
is  to  be  deprecated. 

Food. — Little  food  can  be  taken  dui-int^  a  sharp  pyiexial 
attack,  and  there  is  no  object  in  forcing  any  on  the 
patient  during  this  period.  Thirst  is  a  common  symptom, 
and  there  is  no  reason  why  abundant  fluid  should  not 
be  taken,  provided  that  small  quantities  only  are  taken  at 
a  time,  otherwise  vomiting  may  be  provoked.  Any  fluid 
taken  should  be  hot ;  hot  tea  is  a  favourite  drink,  but 
must  be  freshly  prepared  and  not  too  strong,  as  tannate 
of  quinine  is  very  sHghtly  soluble. 

Many  of  the  native  remedies,  such  as  lemon-grass  tea, 
are  comforting  and  aid  in  diaphoresis.  In  subtertian 
malaria  the  fever  is  long  continued  and  careful  feeding 
is  important.  Milk,  and  milk  and  barley  water  or  other 
light  food  is  usually  retained  and  digested. 

During  convalescence,  protection  from  chill  is  of  great 
importance.  Good  food  is  also  required ;  it  should  be 
light,  nutritious  and  varied,  as  the  appetite  is  frequently 
capricious. 

Few  men  can  be  persuaded  to  remain  long  in  bed  even 
after  a  severe  attack  of  fever,  but  a  minimum  of  three 
days  should  be  insisted  on. 

Special  Cases. — In  pregnant  women  the  frequenc}^  of 
abortion  with  or  without  quinine  must  be  kept  in  mind. 
Unless  the  fever  is  controlled,  abortion  will  take  place 
in  many  cases,  but  quinine,  the  only  reliable  drug, 
undoubtedly  has  a  similar  tendency. 

Before  treating  a  case  of  malaria  in  a  woman,  careful 
enquiries  should  be  made  in  order  to  find  out  if  she  is 
pregnant.  If  so,  quinine  must  be  given,  but  in  very  small 
doses,  gradually  increased  till  the  fever  is  controlled. 
The  large  heroic  doses  advocated  in  an  ordinary  case 
must  only  be  given  in  pregnancy  if  there  is  urgent  danger 
to  life.  A  pregnant  woman  should  be  kept  in  bed  for 
at  least  one  day  before  the   quinine    is   given.     Drastic 


-44  TROPICAL   MEDICINE   AND    HYGIENE 

purgatives  must  be  avoided,  but  a  fair  action  of  the 
bowels  must  be  obtained,  and  the  quinine  given  after  the 
laxative  has  ceased  to  act.  During  the  whole  course  of 
the  treatment  the  patient  must  be  kept  quiet  in  bed. 

If  premature  birth  occurs,  the  child  is  frequently  still- 
born. If  born  alive  it  is  not  infected  with  the  malarial 
parasites  at  birth  in  the  great  majority  of  cases,  but 
exceptions  occur,  and  even  in  England  the  child  of  a 
person  suffering  from  malaria  and  born  in  England  may 
be  found  to  have  malaria. 

A  patient  who  has  had  blackwater  fever  must  be  given 
quinine  very  cautiously.  Unless  there  is  danger  to  life, 
the  doses  must  be  very  small  and  gradually  increased  till 
the  minimum  effective  dose  is  reached. 

Malarial  Cachexia. — The  term  has  been  and  is  much 
abused  and  used  to  cover  many  mistakes  in  diagnosis. 
Conditions  such  as  kala-azar,  ankylostomiasis,  chronic 
dyspepsia  and  its  results  are  so  frequently  mistaken  for  it, 
that  some  authorities  are  tempted  to  abandon  the  term. 

A  real  cachexia  does  follow  repeated  attacks  of  malaria, 
and  is  still  more  marked  in  the  chronic  malarial  condition 
where  parasites  are  present  in  small  numbers  in  the 
blood,  but  are  rarely  sufficiently  numerous  to  cause  sharp 
febrile  attacks,  and  may  not  cause  any  rise  of  temperature 
at  all.  The  condition  does  not  necessarily  occur  in  all 
cases  of  chronic  malaria,  badly  or  irregularly  treated, 
or  even  if  not  treated  at  all,  and  there  are  many  degrees 
of  it  and  varying  complications. 

The  usual  condition  is  one  of  anaemia  with  some  dis- 
coloration of  the  skin  and  associated  with  an  obviously 
enlarged  spleen  and  sometimes  liver. 

The  anaemia  may  be  very  marked  and  the  red  corpuscles 
reduced  to  2,000,000  per  cm.  Such  cases  are  not  common; 
more  frequently  the  reduction  in  the  number  of  cor- 
puscles is  moderate,  three  and  a  half  to  four  and  a  half 
millions,  but  many  of  the  corpuscles  show  signs  of 
degeneration — polychromatic  corpuscles,  corpuscles  with 
basophilic  granules,  poikilocytes — and  great  variation  in 


MAI.AKIAL    CACHEXIA  45 

size  and  colour  of  the  individual  corpuscles.  The  average 
haemoglobin  value  of  the  corpuscles  is  usually  maintained. 

As  the  bronzing  of  the  skin  often  masks  the  anaemia, 
the  conjunctival  and  mucous  surfaces  must  be  examined. 
The  enlarged  spleen  is  hard,  and  as  a  rule  slightly  tender 
on  deep  pressure.  It  may  be  painful.  The  degree  of 
enlargement  does  not  correspond  to  the  anaemia.  The 
liver  is  enlarged  in  some  cases  and  tender.  This  tender- 
ness may  be  so  extreme  as  to  give  rise  to  suspicion  of 
hepatic  abscess.  Associated  with  these  conditions  are 
anorexia,  dyspepsia  and  muscular  weakness.  Insomnia, 
mental  depression  and.  neuralgias  are  common  concomi- 
tants and  may  be  the  most  prominent  symptoms.  In  the 
more  advanced  cases  there  is  oedema  of  the  legs  and 
rarely  albuminuria,  though  in  persons  suffering  from  any 
form  of  Bright's  disease  the  symptoms  of  that  disease  will 
be  aggravated. 

Any  latent  disease  ;  present  is  likely  to  recur  or  be 
aggravated,  and  this  is  specially  the  case  with  syphilis. 

Amongst  the  rarer  complications  are  various  ocular 
disturbances.  Optic  atrophy  or  retinitis  may  occur,  and 
various  forms  of  conjunctivitis.  The  possibility  of  a 
malaria]  complication  must  always  be  considered  in  any 
ocular  disturbances  in  the  Tropics.  Diagnosis  may  be 
very  difficult.  Careful  blood  examination  will  often 
enable  the  diagnosis  to  be  made.  Prolonged  examina- 
tion may  reveal  the  presence  of  an  occasional  malarial 
parasite,  sometimes  of  a  crescent,  sometimes  of  a  ring 
form.  Failing  this,  the  differential  count  may  show  a 
relative  increase  in  the  large  mononuclear  leucocytes, 
and  if  this  be  not  present  it  is  improbable  that  the  case 
is  one  of  malaria. 

In  cases  of  doubt  the  patient  should  be  kept  in  bed, 
alimentary  disturbances  attended  to,  and  quinine  given  in 
moderate  amounts,  either  by  intramuscular  injection  or 
in  solution  by  the  mouth,  5  grains  three  times  a  day. 
Food  should  be  light  and  nutritious,  and  in  a  case  of 
malarial    cachexia   rapid    improvement   will    take    place. 


46  TROPICAL   MEDICINE   AND   HYGIENE 

When  convalesence  has  commenced  the  patient  need  not 
be  confined  to  bed  or  even  to  the  house,  but  quinine 
must  be  continued  for  many  months.  Under  such 
treatment  the  anaemic  condition  rapidly  improves,  but 
can  be  expedited  by  administration  of  small  doses  of 
arsenic  or  of  iron  and  arsenic.  Such  mixtures  as 
Easton's  syrup  in  one-drachm  doses  will  often  be  found 
useful.  Cold  "  bracing  "  climates  should  be  avoided,  the 
warmer  "  relaxing  "  climates  are  more  suitable. 

If  the  weather  be  suitable  when  convalescence  is  well 
established,  as  much  time  as  possible  should  be  spent  in 
the  open  air,  and  exercise,  not  of  a  violent  character  and 
always  short  of  fatigue,  should  be  encouraged. 

The  enlargement  of  the  spleen  at  first  subsides  rapidly, 
but  some  enlargement  will  persist  for  many  months.  It 
is  important  to  be  certain  of  the  diagnosis ;  some  of  the 
milder  cases  of  supposed  malarial  cachexia  are  the  result 
of  too  prolonged  unnecessary  administration  of  quinine, 
and  the  symptoms  will  rapidly  cease  when  quinine  is 
discontinued. 

Ill-eff'ects  of  prolonged  use  of  quinine  are  not  uncom- 
mon. The  ordinary  effects  of  quinine — buzzing  in  the 
ears,  dizziness,  and  so  on — are  not  usually  met  with  in 
persons  who  habitually  take  quinine.  The  main  effects 
are  the  causation  of  chronic,  atonic  dyspepsia  and  its 
sequelae,  and  nervous  depression  or  irritability.  Too  large 
doses  may  cause  permanent  deafness,  but  this  is  rare ; 
more  commonly  gradual  but  complete  recovery  takes  place. 

Amblyopia  may  occur.  The  onset  is  usually  sudden, 
and  both  eyes  are  affected.  The  pupils  are  dilated  and 
do  not  react  to  light.  The  disc  is  pale,  there  is  a  white 
haze  over  the  fundus,  and  the  vessels  are  constricted. 
Vision  is  lost  completely  for  a  time,  but  as  a  rule  there 
is  complete  recovery.  The  condition  is  quite  different 
from  the  still  rarer  optic  neuritis  due  to  malaria,  as  in 
that  condition  the  pupils  react  to  light,  the  fundus  is  con- 
gested, sometimes  there  are  haemorrhages,  and  the  disc 
is  swollen. 


COMPLICATIONS    IN    MyVLARIAL    I'EVEK 


47 


Sequela'. — One  result  of  successful  prevention  of  malaria 
is  a  diminished  death-rate  from  all  causes,  thou;[^h  no 
direct  relation  between  some  of  these  diseases  and  malaria 
can  be  traced. 

Tuberculosis  and  d3'sentery  are  specially  prone  to  attack 
persons  who  are  much  reduced  by  malarial  diseases. 

Boils  and  other  skin  affections  are  very  common,  though 
no  special  type  of  skin  disease  can  be  said  to  be  a  sequela. 

In  individual  instances  there  is  no  proof  of  lowered 
resistance  to  other  diseases,  but  taken  in  mass  the  evidence 
is  strongly  in  favour  of  malaria  inducing  a  condition  in 
a  proportion  of  the  cases  of  increased  susceptibility  to 
bacterial  invasions. 


48 


CHAPTER  V. 

The  parasites,  the  cause  of  malaria,  require  a  careful 
and  detailed  study.  They  may  be  examined  while  still 
living  in  the  freshly  shed  blood,  and  certain  vital  func- 
tions, such  as  the  amoeboid  movements  and  those  of  the 
pigment  of  the  interior  of  the  parasites,  can  only  be  seen 
in  such  preparations.  Other  changes  take  place  in  the 
living  parasites  after  the  blood  is  shed ;  these  are  the 
alterations    in   the   sexual  forms   or   gametocytes   which 


Fig.  i6. 


become   actively  sexual.     The  detailed  structure  can  be 
best  made  out  in  stained  specimens. 

For  the  complete  study  of  the  parasites  both  methods 
of  examination  must  be  employed.  The  blood  may  be 
obtained  by  pricking  the  tip  of  the  finger  or  the  lobe 
of  the  ear.  The  latter  situation  is  most  convenient  in 
children.  The  skin  must  be  clean  and  should  be  rubbed 
over  with  alcohol  and  ether  before  the  puncture  is  made. 


STAINING   OP^   PAKASITES  49 

Preparation  of  Blood  Films. — The  essential  in  the  pre- 
paration of  blood  lilms  for  examination  of  the  parasites 
is  that  the  film  should  be  so  thin  that  the  red  corpuscles 
lie  flat  over  a  considerable  part  of  the  film.  With  fresh 
blood  this  result  can  be  attained  if  the  slides  and  cover- 
glasses  are  free  from  grease  and  grit  so  that  the  bUjorl 
can  run  rapidly,  and  if  the  drop  of  blood  is  so  small 
that  it  does  not  fill  the  whole  space  between  the  slide  and 
cover-glass.  The  edge  of  the  film  will  always  be  too 
thick   and    the    centre    will    contain  too  few  corpuscles. 


Fig.  17. 

The  space  between  should  look  opalescent  and  in  it  the 
corpuscles  lie  side  by  side  flat  (fig.  16,  c).  Dried  films  are 
best  made  with  two  slides.  The  drop  of  blood  should 
be  taken  up  on  the  extreme  edge  of  the  lower  surface  of 
one  slide,  and  then  this  slide  brought  into  contact  with 
the  upper  surface  of  a  second  slide  at  an  angle  of  about 
45°.  The  blood  will  run  along  the  edge  of  contact,  and  if 
the  upper  slide  is  pushed  so  as  to  glide  over  the  surface 
of  the  lower  slide,  a  film  of  blood  suitable  for  examina- 
tion will  be  left  behind  (fig.  17). 

For   general  blood  work  Leishman's   modification  of 
Romano wsky's  stain  is  the  most  generally  useful.     This 

4 


50  TROPICAL   MEDICINE   AND   HYGIENE 

is  the  solution  in  pure  methylic  alcohol  of  the  precipitate 
formed  when  polychrome  methyl  blue  and  eosin  in 
watery  solutions  are  mixed. 

Unfixed  films  must  be  used.  There  are  three  stages 
in  the  process  of  staining  : — 

(i)  The  solution  of  Leishman's  stain  is  placed  on  the 
slide  so  as  to  cover  the  film.  This  fixes  the  film  and 
the  stain  penetrates  the  corpuscles,  but  little  staining 
occurs.  Time,  half  to  one  minute.  The  solution  must 
not  be  allowed  to  dry  on  the  film. 

(2)  Distilled  water  is  added  to  the  solution  of  the  stain 
in  methylic  alcohol  that  has  been  placed  on  the  slide, 
and  the  water  is  rapidly  mixed  with  the  solution.  The 
amount  should  be  sufficient  to  cause  an  abundant  pre- 
cipitate of  the  stain  and  the  mixture  should  appear  pink. 
The  water  should  be  about  double  the  amount  of  the 
solution  used.  It  is  during  this  stage  that  staining  takes 
place.  Time  required,  five  minutes  or  more.  It  is  best  to 
examine  with  a  low  power  under  the  microscope  in  order  to 
see  if  the  leucocytes  are  well  stained,  and  the  nuclei  a  rich 
purple,  before  proceeding  to  the  next  step,  i.e.,  clearing. 

(3)  Clearing.  The  mixture  of  the  w^ater  and  pre- 
cipitated stain  should  be  flushed  off  with  distilled  water. 
A  drop  of  distilled  water  should  be  left  on  the  films 
which  should  be  examined  under  the  microscope.  The 
red  corpuscles  should  not  be  blue,  and  water  can  be  left 
on  until  these  appear  red.  This  takes  half  a  minute  or 
more.  The  water  can  now  be  poured  off  and  the  film 
allowed  to  dry.  It  may  be  blotted,  but  fibres  from 
blotting  paper  are  so  often  mistaken  for  spirochaetae  or 
filariae  that  this  is  not  recommended. 

Parasites  of  Benign  Tertian  and  Quartan. — The  living 
parasites  in  their  earliest  stage  are  colourless  bodies  in 
the  interior  of  the  red  corpuscles.  They  can  be  distin- 
guished from  vacuoles  or  rifts  in  the  red  corpuscles  by  the 
less  sharply  defined  edge  and  by  a  slight  opalescence,  so 
that  they  do  not  appear  quite  so  translucent.  Amoeboid 
movement  can  frequently  be  seen,  and  this  is  often  active 


PARASITES    IN    MALARIAL    FEVER  5I 

though  the  pseudopodia  at  this  stage  are  small.  The 
quivering,  oscillatory  movement  of  the  haemoglobin 
forming  the  edge  of  a  vacuole  must  not  be  mistaken 
for  amoeboid  movement. 

The  parasites  may  be  called  amcebuhe ;  in  the  fresh 
blood  the  parasites  in  this  early  stage  have  not  obviously 
altered  the  red  corpuscle  which  contains  them.  Some 
enlargement  of  the  corpuscle  may  be  seen  in  an  infection 
with  the  parasite  of  benign  tertian  malaria. 

There  is  already  a  change,  as  with  infected  benign 
tertian  parasites  the  red  corpuscles  do  not  crenate  as 
readily  as  the  uninfected  corpuscles.  Sometimes  when 
all  the  other  red  corpuscles  in  a  field  are  crenated,  those 
containing  the  young  forms  are  not  crenated.  On  the 
contrary,  in  a  subtertian  infection,  the  corpuscles  contain- 
ing parasites  crenate  more  readily  ;  sometimes  the  only 
crenated  corpuscle  will  be  one  containing  the  subtertian 
parasite.  In  a  subtertian  infection  the  red  corpuscles 
containing  the  parasites  may  be  altered  in  colour, 
appearing  more  yellow,  the  so-called  "brassy  corpuscles." 

There  is  a  little  difference  in  the  size  of  the  youngest 
parasites  of  benign  tertian  and  quartan,  as  the  quartan 
are  the  larger,  but  both  are  considerably  larger  than  the 
youngest  forms  of  the  subtertian  parasites. 

In  the  blood  examined  a  few  hours  later  in  either 
tertian  or  quartan  malaria  the  parasites  will  be  larger  and 
the  amoeboid  movements  greater  in  extent,  so  that  the 
parasites  are  much  more  irregular  in  shape.  As  a  rule 
the  amoeboid  activity  is  greater  in  tertian  and  the  pseudo- 
podia are  often  finer  and  much  more  irregular  in  shape. 
Pigment  will  be  present  in  both  ;  that  in  tertian  varies 
in  colour,  from  light  brown,  almost  yellow,  to  dark 
brown,  nearly  black,  in  rare  instances.  In  quartan  the 
granules  are  coarser  and  always  black.  The  red  cor- 
puscles containing  the  benign  tertian  parasites  are  swollen 
so  that  they  are  larger  and  paler  than  the  average.  In 
a  quartan  infection  they  are  slightly  smaller,  and  very 
slightly  darker  in  colour  than  the  average. 


52 


TROPICAL   MEDICINE   AND   HYGIENE 


If  the  blood  be  examined  at  intervals  of  a  few  hours 
these  developments  are  gradually  seen  to  become  more 
pronounced.  The  parasites  increase  in  size,  more  and 
more  pigment  is  formed,  brown  and  fine  in  the  tertian, 
coarse  and  black  in  the  quartan.  The  changes  in  the 
red  corpuscles  become  more  marked  (figs.  i8  and  19). 

At  length  the  parasites  nearly  fill  the  red  corpuscles  that 
contain  them  ;  this  requires  rather  less  than  two  days 
with  the  tertian  parasite,  and  less  than  three  days  with 


Fig.  18. — a  to  /,  Phases  in  the  asexual  development  of  the  quartan  parasite  ; 
X  to  z,  phases  in  the  sexual  development. 


the  quartan.  Amoeboid  movements  at  this  stage  cease. 
The  full  growth  is  thus  accomplished,  the  pabulum 
contained  in  the  red  corpuscle  is  exhausted,  and  the 
further  changes  are  those  leading  to  multiplication  and 
reproduction.  This  may  be  asexual  or  sexual.  In  the 
former,  the  most  frequently  seen,  the  first  changes  that 
are   observed   in   the   fresh   blood  are  that  the  pigment 


PARASITES    IN    MALARIAL    FEVKR 


53 


a^fgregcites  in  a  clump  in  the  interior  of  the  parasite. 
This  clump  is  at  first  loose,  so  that  the  individual  grains 
of  pigment  are  easily  distinguished,  but  these  soon  become 
so  closely  packed  that  it  appears  almost  as  a  solid  block 
of  pigment.  By  this  time  traces  of  the  division  in  the 
parasite  will  be  visible.  At  first  these  are  only  seen  with 
difficulty,  but  soon  become  more  marked,  so  that  the 
whole  of  the  protoplasm,  except  a  minute  residuum  round 


cy-  o 
r5£V 


'WS^ 


Fig.  19. — a  to  /,   Phases  in  the  asexual  development  of  the  benign  tertian 
parasite  ;  x  to  z,  phase  in  the  sexual  development. 


the  pigment,  is  divided  into  a  series  of  oval  unpigmented 
masses,  five  to  ten  in  number  in  quartan  and  eighteen  to 
twenty-four  in  benign  tertian.  Very  rarely  a  larger  or 
smaller  number  of  those  ovoid  masses — spores — maj^  be 
found  in  these  sporulating  parasites.  The  red  corpuscles 
containing  the  parasites  soon  burst,  and  the  spores,  pig- 
ment, residual  protoplasm,  and  any  fluid  or  solid  residue 
of  the  red  corpuscle,  probably  including  toxic  substances. 


54  TROPICAL   MEDICINE   AND   HYGIENE 

are  set  free  in  the  blood  plasma.  The  pigment  is  taken 
up  by  leucocytes,  usually  by  the  large  mononuclear 
leucocytes. 

The  spores  do  not  long  remain  free  in  the  peripheral 
blood ;  they  rapidly  try  to  enter  other  red  corpuscles. 
Many  must  fail  to  do  so  and  be  rapidly  destroyed,  as 
the  number  of  young  parasites  found  is  far  less  than 
it  would  be  if  all  the  spores  were  able  to  enter  red 
corpuscles  ;  nor  does  the  rapid  increase  in  the  number 
of  parasites  occur  with  the  successive  sporulations  as 
might  be  expected. 

This  process  of  reproduction  is  commonly  termed 
sporulation,  but  is  more  correctly  termed  schizogony. 
The  sporulating  parasites  would  then  be  known  as 
schizonts  and  the  spores  as  inerozoites. 

Sexual  Phase. — Sporogony.  The  parasites  destined  for 
a  sexual  life  in  benign  tertian  and  quartan  malaria  are 
not  unlike  full-grown  parasites  before  any  indication 
of  sporulation  has  taken  place.  When  nearly  full-grown 
they  can  be  distinguished  from  these,  because  there  is 
always  a  rounded  space  free  from  pigment  and  slightly 
more  retractile  to  light  enclosed  in  the  parasite.  These 
forms  may  be  found  at  any  period,  and  are  usually  less 
numerous  that  the  schizonts.  They  undergo  no  further 
development  in  the  peripheral  blood. 

In  the  shed  blood  further  development  takes  place,  and 
can  be  observed  in  a  thin  blood  film  under  the  micro- 
scope. The  sexual  forms,  ganietocytes,  are  potentially 
male  and  female  in  the  freshly  shed  blood,  but  it  is 
practically  impossible,  in  the  parasites  of  benign  tertian 
and  quartan,  to  distinguish  at  first  the  males  from  the 
females.  After  a  short  time  if  the  blood  has  been  exposed 
to  air  or  has  had  water  added  to  it,  and  still  more  rapidly 
in  the  stomach  of  the  mosquito,  they  become  sexually 
active. 

Sexual  Multiplication. — The  first  change  that  can  be 
seen  is  that  the  parasites  become  more  definitely  rounded 
and   the   pigment   appears   to    be    in    active   movement, 


SEXUAL    PARASITES    IN    MALARIA  55 

indicatintf  movements  in  the  protoplasm.     Tlie  remnants 
of  the  red  corpuscles  which  had  enclosed  them  disappear. 

In  both  male  and  female  forms  the  next  sta^e  is  the 
extrusion  of  a  considerable  part  of  the  protoplasm,  so 
that  there  are  two  bodies  of  unequal  size,  the  smaller 
being  the  polar  body.  Tiie  females  ordinai-ily  do  not 
undergo  any  further  change,  as  seen  on  the  slide  ;  they 
are  now  in  the  receptive  condition  awaiting  fertilization, 
and  are  called  inacrogametcs.  The  males  do  change. 
In  the  larger  of  the  two  masses,  into  which  the  parasite 
has  divided  ;  violent  movement  of  its  pigment  occurs,  and 
it  suddenly  projects  three,  four,  or  five  thin,  long  flagella, 
which  are  free  from  pigment  and  actively  motile,  lashing 
the  neighbouring  red  corpuscles.  These  flagella,  known 
as  microgarnetes,  are  the  male  fertilizing  elements,  the 
equivalent  of  spermatozoa.  After  a  time  they  detach 
themselves  from  the  mass  of  residual  protoplasm  in 
which  the  pigment  is  included,  and  swim  freely  in  the 
blood  plasma.  They  have  been  seen  to  fertilize  the 
female  or  macrogamete.  The  residual  protoplasm  and 
pigment  are  swallowed  by  surrounding  leucocytes, 
usually  the  large  mononuclear  ones,  rarely  the  poly- 
morphonuclear. The  pigment  is  not  digested  by  these 
leucocytes,  but  is  carried  by  them  to  the  spleen  or  liver, 
and  there  deposited  in  cells  and  connective  tissue. 

Parasites  in  all  stages  in  benign  tertian  and  quartan 
malaria  may  be  seen  in  a  series  of  consecutive  examina- 
tions. The  sporulating  forms  are  not  so  numerous  in 
the  peripheral  blood  as  the  younger  forms,  as  a  con- 
siderable proportion  of  the  corpuscles  containing  the 
full-grown  and  sporulating  forms  seem  to  be  detained 
in  the  splenic  sinuses.  At  any  one  time  either  all  the 
parasites  are  about  the  same  age,  or  those  of  one  set 
are  twenty-four  hours  older  or  younger  than  the  others. 
It  is  very  unusual  to  find  parasites  in  the  intermediate 
stages  of  growth  ;  it  follows  from  this  that  the  sporulation 
of  a  large  number  of  the  parasites  is  nearh^  synchronous. 

If  there  is  only  one  generation  the  successive  sporula- 


56 


TROPICAL   MEDICINE   AND   HYGIENE 


tions  are  at  intervals  of  forty-eight  hours  in  the  tertian 
and  seventy-two  in  the  quartan.  If  there  are  two  genera- 
tions, in  tertian  they  will  sporulate  on  successive  days, 
but  the  sporulation  of  the  individuals  of  each  generation 
is  synchronous. 

In  quartan  there  may  be  at  the  same  time,  one,  two, 
or  three  generations.  When  there  are  three  they  will 
sporulate  on  three  consecutive  days.  Where  there  are 
two  generations,  on  two  consecutive  days  .with  one  day's 
interval. 


Table  of  Differences  between  the  Parasites  of  Malaria. 


Benign  tertian 

Quartan 

Subtertian 

(i)  Length  of  cycle, 

48  hours 

72  hours 

Uncertain,  often  about 

i.e.,  interval  be- 

48   hours   or     rather 

tween  one  sporu- 

less. 

lation  and    the 

next 

(2)  Size  of  mature 

Larger  than  the 

Slightly  smaller 

About  half  the  diameter 

parasite 

average  red  cor- 

than the  aver- 

of an  average  red  cor- 

puscle 

age    red    cor- 
puscle 

puscle. 

(3)  Number        of 

18—24 

6 — 10 

Variable,  6 — 30. 

"  spores" 

(4)  A  m  oe  b  0  i  d 

Active  and   ex- 

Sluggish 

Very  active,  but  range 

movement 

tensive 

of  movement  not  ex- 
tensive. 

(5)  Gametocytes 

Rounded  bodies 

Rounded  bodies 

Sausage-shaped  bodies, 
"  crescents." 

(6)  Pigment 

Finely    divided 

Coarse  and  black 

Black  and  at  first  finely 

and  brown 

divided,  but  soon  ag- 
gregating into  coarse 
clumps. 

(7)  Effect   on  red 

Causes  it  to  swell 

Red     corpuscle 

The     young      parasite 

corpuscle   serv- 

and     become 

becomes  slight- 

causes   little    or     no 

ing  as  host 

paler.       Does 

ly  smaller  and 

alteration,  but  some- 

not crenate  so 

darker 

times    the   corpuscles 

readily.         In 

become       yellower — 

stained    speci- 

"brassybodies."  The 

mens     Schliff- 

older     parasites     de- 

ners'dots  often 

colorize  the  red  cor- 

found 

puscles  irregularly. 

Parasites  in  Subtertian  Malaria. — The  results  of  the 
examination  of  fresh  blood  in  subtertian  fever  (malignant 
tertian)  differ  in  important  points. 


PARASITES   IN    MALARIAL    FKVKR  57 

In  the  great  majority  of  cases  during  the  febrile  period, 
only  small  parasites  free  from  pigment  are  found.  These 
are  usually  actively  amoeboid,  but  the  changes  in  shape 
are  slight.  The  smallest  forms  are  smaller  than  any 
forms  in  benign  tertian  or  quartan.  The  red  corpuscle 
containing  the  parasite  crenates  readily,  but  the  corpuscle 
is  usually  of  the  average  size  and  colour  ;  sometimes  it  is 
more  yellow  and  brassy. 

Parasites  at  this  stage  may  be  found  at  each  successive 
examination  extending  over  a  period  of  several  days,  but 
are  usually  more  numerous  at  one  time  than  at  another. 
At  some  of  the  examinations  they  may  not  be  found, 
whilst  a  few  hours  later  they  may  be  numerous.  It  is 
common  to  find  a  few  slightly  larger  parasites  with  more 
extensive  amoeboid  movements,  and  containing  finely 
divided  black  pigment  (fig.  20,  a,  h). 

More  advanced  stages  are  very  rarely  seen,  but  para- 
sites with  the  pigment  aggregated  in  a  dense  black  block, 
and  even  sporulating,  are  occasionally  found.  Some- 
times, usually  just  before  death,  such  forms  may  even 
be  numerous  (fig.  20,  c,  d,  e).  These  advanced  forms  are 
abundant  in  the  capillaries  in  the  internal  organs  and 
appear  to  be  accidental  only  in  the  peripheral  circulation. 

In  addition  to  the  young  forms  of  the  parasites,  game- 
tocytes  are  also  found  in  the  peripheral  blood.  These 
are  not  present  in  the  early  stages  of  the  fever,  and  are 
rarely  numerous  when  there  is  pyrexia,  and  young  forms 
are  abundant ;  they  are  more  common  after  the  pyrexia 
has  disappeared,  and  when  no  young  forms  can  be  found, 
and  are  therefore  numerous  during  convalescence  from 
a  febrile  attack. 

The  gametocytes  of  subtertian  malaria  are  of  a  special 
shape  and  quite  different  from  the  sporoc3'tes  of  sub- 
tertian  or  the  gametocytes  of  the  other  forms  of  malaria. 
They  are  sausage-shaped  bodies,  longer  than  the  diameter 
of  a  red  corpuscle,  and  the  ends  are  free  from  pigment ; 
this  is  aggregated  into  a  clump  near  the  centre  (fig.  20,  .v). 
In  the  freshly  shed  blood  they  are  still  enclosed  in  a  red 


58 


TROPICAL   MEDICINE   AND   HYGIENE 


corpuscle,  but  this  is  almost  colourless  and  stretched 
out  by  the  parasite.  If  these  gametocytes,  the  potentially 
sexual  forms,  are  examined  closely,  it  will  be  seen  that 
in  some  there  is  a  space  free  from  pigment  in  the  centre 
of  the  clump  of  pigment  ;    these  are  the  female  forms. 


Fig.  20. — a  to  e,  Phases  in  the  asexual  development  of  the  malignant 
malarial  parasite ;  x  to  z,  phases  in  the  sexual  development — x  y  z,  of  the 
female  ;  X '  jj/ '  2 ',  of  the  male. 

In  the  others  there  is  no  such  clear  space,  and  the  pig- 
ment clump  is  larger  and  less  regular.  These  are  the 
male  forms  (fig.  20,  ;r^). 

If   watched  for   a   time  varying   with    different   cases, 


PARASITES    IN    MALARIAL    FEVIiR  59 

and  in  the  same  case  on  different  occasions,  the  game- 
tocytes  are  seen  to  become  actively  sexual.  The  first 
change  in  both  is  that  the  parasites  become  shorter  and 
broader,  first  ovoid  and  finally  circular  or  spheroidal. 
The  remnants  of  the  red  corpuscle  disappear.  One  or 
two  small  retractile  globules,  the  polar  bodies,  are 
extruded,  and  there  is  much  agitation  of  the  pigment. 

The  females — macrogametes — unless  fertilized  undergo 
no  further  change  (fig.  20,  y,  z).  The  males  flagellate  and 
the  flagella  ultimately  separate  from  the  residual  proto- 
plasm which  contains  all  the  pigment  and  swim  about 
freely  in  the  blood  plasma  (fig.  2o,y^,z^).  They  have  been 
seen  to  enter  and  fertilize  the  female  or  macrogamete. 
This  is  the  first  stage  in  the  sexual  cycle  of  the  malaria 
parasites.  The  macrogamete  when  fertilized  is  a  zygote, 
i.e.,  the  product  of  conjugation.  .  .  .  This  zygote  is 
actively  motile,  creeping  and  moving  like  a  gregarine,  it  is 
now  known  as  the  travelling  vermicule  or  ookinet.  The 
further  changes  in  the  zygote,  by  which  the  contents 
ultimately  divide  into  a  mass  of  minute  thread-like  bodies, 
the  sporozoites,  takes  place  in  the  stomach  wall  of  the  mos- 
quito between  the  epithelial  and  musculo-membranous 
layers  (fig.  21).  This  series  of  events  is  known  as  the 
sexual,  exogenous,  or  mosquito  cycle,  and  by  parasitolo- 
gists as  sporogoiiy.  The  sporozoites  ultimately,  in  eight 
days  or  more  according  to  the  temperature,  accumulate 
in  cells  in  the  salivary  glands  of  the  mosquito  and  are 
injected  with  the  saliva  of  that  insect  into  man.  After 
this,  in  eight  to  twelve  days,  the  young  amoeboid  forms 
of  the  parasite  will  be  found  in  the  man  so  injected  if  he 
be  susceptil:)le. 

Stained  Films. — In  blood  films  stained  by  Leishman's 
method  the  various  stages  can  also  conveniently  be 
studied,  and  certain  points  in  the  cell  structure  can  only 
be  brought  out  in  such  specimens. 

Leishman's  stain  is  practicall}^  a  triple  stain  ;  it  contains 
eosin,  which  has  a  special  affinity  for  formed  material  but 
not  for  parts  of   cells  actively  concerned  in    growth  or 


6o 


TROPICAL   MEDICINE   AND   HYGIENE 


reproduction.  It  is  a  so-called  acid  stain,  and  stains 
the  haemoglobin  in  blood  and  some  of  the  granules  in 
certain  leucocytes.  It  stains  faintly  the  protoplasm  of 
some  of  the  leucocytes.  The  methylene  blue  has  been 
altered  by  the  polychromingso  that  two  stains  are  present, 
both  basic.  A  blue,  the  unaltered  methylene  blue,  which 
stains  the  ordinary  cell  protoplasm  or  actively  growing 
cells,  parts  of  the  nuclei,  granules  said  to  be  basophilic  in 


Fig.  21. 


some  of  theTed  corpuscles,  and  faintly  but  diffusely  other 
degenerate  red  corpuscles.  It  also  stains  the  nuclei  of 
any  red  corpuscles  that  still  possess  them,  and  stains 
faintly  the  blood  platelets. 

The  altered  methylene  blue,  red  in  colour,  but  a  deeper 
red  than  that  of  eosin,  has  a  special  affinity  for  certain 
substances  constantly  present  in  actively  growing  cells 
known  as  chromatin.     In  the  nuclei  this  substance  is  in 


PAKASITES    IN    MALARIAL    KKVER  6l 

abundance  and  especially  concerned  in  processes  of 
multiplication  and  reproduction. 

Ot  the  blood  elements  this  red  polychrome  methylene 
blue  stains  the  nuclei  of  the  leucocytes  so  that,  as  they 
are  also  stained  with  the  unaltered  methylene  blue,  they 
appear  purple.  It  also  stains  granules  present  in  the 
protoplasm  of  some  of  the  large  mononuclear  leucocytes, 
and  granules  or  a  network  in  the  blood  platelets. 

As  regards  the  parasites  of  malaria  the  young  forms 
with  Leishman  stain  show  a  nodule  of  chromatin  con- 
tained in  a  large  non-staining  nucleus,  a  so-called  "  vesi- 
cular nucleus."  This  vesicular  nucleus  is  surrounded  by 
a  narrow  rim  of  protoplasm  which  stains  blue  with  the 
unaltered  methylene  blue.  The  whole  forms  the  "  ring 
form  "  of  the  parasite  and  in  the  stained  specimen,  as  in 
the  unstained,  it  is  difficult  to  distinguish  between  the  dif- 
ferent species  of  parasites  in  this  stage  (Plate  I.,  i,  7,  10,  16). 

The  older  the  parasite  is,  the  more  abundant  the  pro- 
toplasm surrounding  the  vesicular  nucleus  becomes,  as 
growth  is  mainly  by  an  increase  in  the  protoplasm. 
Where  the  protoplasm  is  relatively  abundant  the  parasite 
is  not  a  young  one.  A  ring  form  that  is  still  small,  when 
from  the  relative  amount  of  the  protoplasm  it  is  known 
not  to  be  young,  is  probably  a  subtertian  parasite.  A  very 
small  ring  form  is  also  probably  a  subtertian,  as  the  very 
young  subtertian  parasites  are  smaller  than  either  tertian 
or  quartan. 

The  chromatin  nodules  in  half-grown  benign  tertian 
and  quartan  are  easily  distinguished.  The  vesicular 
nucleus  is  still  present  and  the  chromatin  no  longer 
appears  to  be  a  solid  block,  as  it  seems  to  be  composed 
of  several  fragments.  In  deeply  stained  films  of  benign 
tertian  granules  staining  red,  Schiiffner's  dots,  can  be  seen 
throughout  the  red  corpuscle  containing  the  parasites 
(Plate  I.,  7,  8,  9). 

Later  in  both  tertian  and  quartan  forms  the  vesicular 
nucleus  and  the  chromatin  mass  break  up  and  the  whole 
parasite  stains  irregularly  blue. 


62  TROPICAL   MEDICINE   AND   HYGIENE 

Before  sporulation,  chromatin  masses  again  appear  in 
the  periphery  of  the  parasite.  At  first  these  are  few,  but 
later  they  are  more  numerous,  one  corresponding  to 
each  spore  or  division  into  which  the  protoplasm  divides. 
When  fully  formed  each  spore  contains  a  nodule  of 
chromatin  embedded  in  an  oval  mass  of  protoplasm 
which  stains  blue.  The  vesicular  nucleus  is  indicated 
by  less  deep  staining  near  the  chromatin,  but  is  not 
sharply  defined  as  it  is  in  the  spore  after  it  has  entered 
the  red  corpuscles  (Plate  I.,  4,  5,  14,  15). 

The  corresponding  forms  in  subtertian  malaria  are  very 
rarely  found  in  the  peripheral  blood. 

The  gametocytes  of  quartan  and  tertian  can  be  readily 
recognized  in  the  stained  specimens. 

The  space  free  from  pigment  does  not  stain  uuth  the 
unaltered  methylene  blue,  but  contains  numerous  granules 
usually  forming  a  clump  of  chromatin,  which  stains  less 
deeply  than  the  chromatin  of  the  sporocytes. 

In  a  stained  flagellum  a  narrow  strip  of  chromatin  is 
seen  in  the  middle.  The  polar  bodies  also  contain 
chromatin. 

In  the  gametocytes  of  subtertian  malaria — crescents — 
chromatin  is  in  a  different  state  of  aggregation  in  the 
males  and  the  females.  In  the  females  the  chromatin 
forms  a  nearly  solid  block  in  the  centre  of  the  clear  space 
enclosed  by  a  ring  of  pigment.  In  the  males,  the  chroma- 
tin is  more  abundant  but  does  not  form  a  solid  block,  but 
a  series  of  coarse  granules  scattered  about  between  and 
beyond  the  grains  of  pigment  (Plate  I.,  18,  19).  The 
chromatin  in  the  gametocytes  of  all  forms  of  malaria 
stains  only  with  the  altered  forms  of  methylene  blue.  It 
does  not  stain  with  haematoxylin  or  with  most  basic  stains. 

It  is  doubtful  if  all  the  parasites  described  here  as 
"  subtertian  "  are  of  one  and  the  same  species.  By  some 
of  the  Italian  authorities  they  are  subdivided  into  three 
species,  viz.,  pigmented  quotidian,  unpigmented  quotidian, 
and  malignant  tertian,  whilst  others  attempt  to  subdivide 
into  two  species  only.     Any  classification  based  on  the 


PARASITES    IN   MALAHIAL    KEVEK  63 

periodicity  of  the  fever  with  tliis  class  of  parasites  is 
unrehable,  as  there  is  not  a  suflicient  synchronicity  in 
the  stages  of  the  parasite  for  any  marked  regularity  to 
be  expected.  In  practice  one  type  of  fever  may  pass 
gradually  into  another  type  without  any  change  in  the 
characters  of  the  parasites  found. 

In  the  majority  of  cases  there  are  few  or  no  pigmented 
parasites  to  be  found  in  the  peripheral  blood,  but  in  these 
cases,  if  fatal,  the  full-grown  parasites  found  in  the  internal 
organs  are  always  pigmented. 

As  regards  the  enquiry  as  to  the  differentiation  into 
species  of  the  parasites  having  gametocytes  of  a  sausage- 
shape — crescents — we  find  : — 

(1)  That  the  length  of  cycle  is  very  difficult  to  ascertain, 
as  the  later  stages  of  development  are  not  found  in  the 
peripheral  blood,  and  that  parasites  of  all  stages  may  be 
present  at  the  same  time, 

(2)  That  the  parasites  are  comparatively  small,  but  full- 
grown  parasites  from  less  than  half  to  two-thirds  the 
diameter  of  the  red  corpuscle  are  to  be  found  in  the 
same  case. 

(3)  That  all  may  be  actively  amoeboid,  that  in  all  the 
pigment  when  first  seen  is  finely  divided,  and  that  in  all 
in  the  older  parasites  the  pigment  is  coarse  and  black. 

(4)  The  number  of  spores  varies  within  very  wide 
limits.  In  some  cases  the  number  of  spores  found  is 
small  in  all  the  sporulating  parasites  seen.  In  others  the 
number  of  spores  formed  is  large  in  all.  Speaking 
generally,  it  is  much  rarer  to  find  the  parasites  with  six  to 
eight  spores  than  those  with  a  larger  number. 

(5)  Effect  on  the  red  blood  corpuscle  :  This  certainly 
varies,  but  does  so  as  much  from  day  to  day  in  the  same 
patient  as  in  different  persons.  Brassy  bodies  may  be 
very  numerous  on  one  day,  but  though  the  patient  is  not 
treated  and  the  parasites  continue  to  be  numerous,  none 
at  all  may  be  found  two  or  three  days  later. 

(6)  Toxic  Effects. — Haemolysis  may  be  marked  or  very 
slight,  and  in  some  countries  these  hasmolytic  effects  are 


64  TROPICAL   MEDICINE   AND   HYGIENE 

very  common  and  in  others  rare.  This  may  indicate  a 
difference  in  species.  Other  effects,  such  as  albuminuria, 
are  common  in  some  districts  and  rare  in  others.  In 
these  cases  no  morphological  differences  in  the  parasites 
can  be  demonstrated.  It  is  possible  that  there  are  dif- 
ferent species  of  parasites,  but  it  cannot  be  considered 
as  proved.  Possibly  the  differences  in  toxic  effects^of  the 
parasites  may  be  effected  by  variations  in  the  environ- 
ment of  the  parasites  during  their  sexual  or  exogenous 
cycle,  as  in  different  places  different  mosquitoes  serve 
as  hosts,  and  slight  alterations  in  temperature  markedly 
affect  the  rate  of  growth  and  development  of  the  parasites 
whilst  developing  in  the  mosquitoes. 


65 


CHAPTER  VI. 

Etiology. — It  is  not  necessary  to  do  more  than  allude 
to  the  older  hypotheses  as  to  the  causation  of  malaria. 
These  were  mainly  founded  on  the  belief  that  emanations 
from  decomposing  vegetables  or  from  soil  or  rocks  such  as 
granite  caused  the  fever.  These  emanations  were  known 
as  "  miasma,"  and  were  believed  to  rise  only  a  short  dis- 
tance from  the  ground  during  the  night  and  to  be  dissi- 
pated by  the  sun.  It  is  from  this  hypothesis  that  the 
term  for  the  disease,  malaria,  is  derived.  These  observa- 
tions as  to  the  occurrence  of  malaria  are  in  many  cases 
more  readily  explained  now  that  it  is  known  that  the 
disease  is  carried  by  mosquitoes. 

We  now  know  that  malaria  is  a  parasitic  disease,  and 
that  the  parasites  are  conveyed  from  man  to  man  by 
certain  species  of  mosquitoes.  As  far  as  we  know  these 
parasites  can  only  exist  in  man  and  mosquitoes. 

Malaria  can  be  propagated  from  man  to  man  by  trans- 
fusion or  by  the  injection  of  the  blood  of  a  malarial 
patient  into  another  person,  but  this  method  of  trans- 
mission can  play  no  part  in  the  natural  dissemination  of 
the  disease. 

The  proofs  of  the  mosquito  malaria  hypotheses  are  as 
follows  : — 

(i)  The  development  day  by  day  of  the  parasites  can 
be  followed  in  a  batch  of  mosquitoes  fed  on  a  person 
in  whose  blood  gametocytes  are  found.  This  is  so 
definite  that,  knowing  the  time  that  has  elapsed  since 
the  mosquito  was  fed,  the  appearance  of  the  malarial 
parasite  in  it  can  be  predicted  with  certainty.  No  such 
bodies  are  found  in  other  mosquitoes  bred  from  larvae. 
When  these  parasites  have  reached  a  certain  stage  of 
5 


66  TROPICAL   MEDICINE   AND   HYGIENE 

development,  the  sporozoites  are  found  in  the  sahvary 
glands  of  these  mosquitoes,  and  if  such  mosquitoes  be 
allowed  to  bite  any  susceptible  person,  he  will,  after  a 
period  of  incubation,  develop  malaria  of  the  same  type 
as  that  of  the  man  on  whom  the  mosquito  fed. 

(2)  Mosquitoes  were  allowed  to  feed  on  a  patient  with 
malaria  in  Italy,  and  transported  to  London.  These  fed 
on  two  uninfected  persons  there  and  these  persons  then 
developed  malaria. 

(3)  It  has  been  further  shown  that  people  can  live  in 
malarial,  swampy  country,  such  as  the  Campagna,  and 
that  so  long  as  they  are  protected  from  bites  of  mosquitoes 
they  will  be  free  from  malaria,  though  other  inhabitants 
suffer. 

(4)  Certain  islands  in  the  Tropics  are  free  from  malaria, 
though  neighbouring  islands  in  sight  are  intensely 
malarious,  e.g.,  Barbados  is  free  from  malaria,  whilst 
in  St.  Vincent  it  is  abundant.  It  is  found  that  in  the 
malaria-free  island  no  mosquitoes  capable  of  carrying 
malaria  exist,  whilst  in  others  they  are  common.  Fiji 
may  be  quoted  as  an  exception  as  there  is  no  malaria 
there,  and  amongst  the  many  mosquitoes  sent  from  that 
country  one  wing  of  an  anopheline  was  found.  No  others 
have  been  found  though  they  have  been  looked  for. 

(5)  The  success  of  anti-malarial  operations  which 
diminish  the  liability  to  be  bitten  by  malaria-carrying 
mosquitoes  by  diminishing  the  number  of  those 
mosquitoes  is  an  additional  proof  of  the  correctness  of 
the  hypothesis.  In  places,  such  as  Ismailia  and  Kwala 
Klang,  where  the  reduction  in  the  number  of  these 
anophelines  was  great,  the  cases  of  malaria  diminished 
to  one-tenth  or  less.  In  many  other  places  where  the 
reduction  in  the  number  of  these  mosquitoes  was  less, 
there  was  still  a  decided  diminution  in  the  amount  of 
malaria. 

(6)  In  many  parts  of  Africa  the  liability  to  malarial 
infection  in  the  settlements  is  very  closely  related  to 
the  actual  number  of  malaria-bearing  mosquitoes. 


ETIOLOGY   OF   MALARIAL   P^EVEK  67 

It  is  often  urged  that  although  this  is  one  way  in  which 
malaria  is  caused,  there  may  be  others.  It  is  possible 
that  in  other  blood-sucking  insects  a  similar  development 
of  the  parasites  might  take  place,  but  there  is  no  evidence 
in  favour  of  such  a  view,  and  it  is  exceptional  for  protozoa 
to  be  equally  capable  of  similar  development  in  widely 
separated  groups  of  arthropoda. 

The  success  of  prophylactic  measures  used  on  the 
hypothesis  that  certain  mosquitoes  are  the  carriers  of 
malaria  shows  that  this  at  any  rate  is  the  important 
method  of  the  propagation  of  malaria.  If,  when  the 
possibility  of  this  method  of  conveyance  is  removed, 
malaria  still  continued  to  exist  in  any  place,  special 
enquiry  would  be  required,  but  no  such  instances  are 
known  at  present.  For  prophylactic  work,  therefore, 
the  known  method  in  which  the  disease  is  carried  is  the 
only  one  now  to  be  considered. 

Some  knowledge  of  insects  in  general,  and  mosquitoes 
in  particular,  is  essential  to  advise  as  to  economic  prophy- 
lactic measures,  and  an  outline  of  the  classification  of 
insects,  and  the  principles  on  which  the  mosquitoes  are 
classified,  is  given  in  a  separate  chapter  as  an  appendix. 

The  known  carriers  of  malaria  all  belong  to  the  division 
of  the  mosquitoes  known  as  Anophelina.  The  anophe- 
lines  do  not  serve .  equally  well  as  carriers  of  malaria. 
Some  species  are  readily  infected,  others  only  with  diffi- 
culty, and  some  not  at  all.  The  dangerous  species  are 
those  which  are  numerous  and  readily  convey  the  disease. 

For  economic  and  efficient  prophylaxis  a  knowledge 
of  the  habits  of  each  species  is  required,  and  it  is  found 
that  the  different  species  vary  greatly  in  their  habits,  life- 
history,  and  breeding-places. 

In  any  place  or  country  the  species  of  anophelines 
must  be  determined;  those  that  are  good  carriers  of 
malaria  must  be  found  out  experimentally,  and  the 
breeding  places  and  habits  of  these  must  be  studied  in 
great  detail. 

The  anophelines,  which  include  all  the  known  carriers 


68  TROPICAL   MEDICINE   AND   HYGIENE 

of  human  malaria,  are  easily  distinguished  from  other 
mosquitoes,  which  have  a  straight,  penetrating  proboscis, 
(i)  The  palps  in  both  male  and  female  are  practically 
the  same  length  as  the  proboscis,  and  in  the  male  are 
clubbed  (fig.  22). 

(2)  The  scutellum,  which  is  more  or  less  trilobed  in 
other  mosquitoes,  shows  no  sign  of  such  lobing  in  the 
anophelines. 

(3)  The  scales  on  the  veins  of  the  wings  are  lanceolate 
in  the  anophelines,  whilst  they  vary  greatly  in  the  other 
Culicidce  (fig.  23). 

(4)  The  proboscis  is  nearly  in  the  long  axis  of  the 
head,  thorax  and  abdomen,  so  that  the  mosquito  almost 
forms  a  straight  line.  When  at  rest,  as  the  proboscis 
points  towards  the  surface  on  which  the  mosquito  rests 
the  abdomen  points  away  from  it  (fig.  24). 

(5)  The  larvae  have  no  respiratory  syphon ;  they  lie 
flat  on  the  surface  of  the  water  when  at  rest,  and  have 
compound  "  palmate  "  tufts  along  each  side  of  the  abdo- 
men on  the  latero-dorsal  aspect. 

(6)  The  eggs  are  more  or  less  boat-shaped,  and  have 
lateral  air-floats  ;  they  are  laid  singly  and  not  formed  into 
rafts. 

For  the  propagation  of  malaria  all  that  is  required  is  : — 
(i)  That  suitable  anophelines  should  feed  on  a  person 
in  whose  blood  sexually  mature  parasites — gametocytes — 
are  present  ;  (2)  that  these  mosquitoes  should  be  kept  at 
a  proper  temperature  for  a  period  varying  according  to 
the  temperature,  from  about  eight  to  some  sixteen  days 
or  more  ;  and  (3)  should  then  bite  a  person  susceptible 
to  malaria.  In  about  ten  to  fourteen  days  such  a  person 
will  develop  malarial  fever.  As  far  as  is  known  man  is 
the  only  animal  that  ever  acts  as  the  intermediate  host 
for  the  species  of  parasites  which  cause  malarial  fever 
in  man,  and  therefore  mosquitoes,  the  definitive  hosts, 
derive  the  parasite  from  man  only,  and  transmit  it  to 
man  only.  Any  break  in  the  sequence  will  result  in  the 
destruction  of  the  parasites,  and  it  is  with  this  in  view 
that  all  attempts  at  prophylaxis  must  be  conducted. 


Fig.  22.--I,  Culicine  male  ;   2,  Culicine  female;    3,  Anopheline  male; 
4,  Anopheline  female. 


Anopheles. 


Cyclolepteron. 


lanthinosoma. 


Mansonia, 


Stegomyia. 


Eretmapodites. 


Mucidus. 


Psorophora. 


Fig.  23. — Various  Forms  of  Wing- scales  (Theobald),  i,  Scales  on  veins 
and  on  costa  in  Anopheles ;  2,  scales  on  veins  in  Cyclolepieroyi  ;  3,  scales  on 
veins  and  on  costa  in  /anthiiiosoma ;  4,  scales  on  veins  in  Mansonia ;  5, 
scales  on  veins  in  Stegomyia ;  6,  scales  on  veins  in  Eretmapodiies ;  7,  scales 
on  veins  and  on  costa  in  Culex  ;  8,  scales  on  veins  in  Mucidtis  ;  9,  scales  on 
veins  and  on  costa  of  Psorophora. 


Fig.  24. — A,  Lateral  view  of  Anopheline  ;  B,  lateral  view  of  Culicine  ;  C,  anopheline 
viewed  from  above;  D,  culicine  viewed  from  above;  E,  head  of  Corethra  ;  F,  head  of 
Megarhinina. 


72  TROPICAL   MEDICINE   AND   HYGIENE 

I.  The  parasites  in  man  can  be  attacked  by  the  use  of 
quinine  in  all  infected  persons,  so  that  the  chances  of  the 
mosquitoes  becoming  infected  are  much  diminished. 
Persons  may  be  rendered  insusceptible  by  the  free  use 
of  quinine,  so  that  even  if  infected  mosquitoes  bite,  the 
parasites  do  not  develop.  This  affords  protection  to 
the  individual,  but  either  of  these  measures  to  be  successful 
requires  practically  universal  dosing  with  quinine. 

II.  Increased  protection  from  mosquito  bites  by 
mosquito  nets,  clothing  better  adapted  for  protection 
against  mosquitoes,  mosquito-proof  houses  and  the  more 
general  and  intelligent  use  of  mosquito  nets,  are  all 
measures  that  may  alone  under  exceptional  circum- 
stances prevent  infection,  and  in  any  case  are  of  great 
value  in  diminishing  the  opportunities  for  infection, 
either  of  man  or  of  the  mosquito. 

III,  Avoiding  places  where  mosquitoes  are  probably 
infected,  in  travelling  by  land,  and  sleeping  in  the 
native  huts  or  in  the  same  clearing  as  the  native  village 
should  be  avoided.  It  is  safer  to  make  the  encampment 
in  the  jungle,  a  mile  or  so  from  the  native  settlements. 
Rest  houses  and  bungalows  should  not  be  built  in  or 
near  to  a  native  settlement  ;  if  they  are  in  such  situations 
they  should  be  avoided. 

Mosquitoes  acquire  the  malarial  parasite  only  from 
man,  and  there  is  no  reason  to  suppose  that  it  can  be 
conveyed  to  the  mosquitoes  from,  any  other  source. 
Anophelines  may  be  present  in  a  place  in  large  numbers, 
and  yet  there  may  be  no  malaria ;  if,  however,  they  bite 
men  already  infected  with  malaria  they  will  spread  the 
disease  and  that  place  will  then  become  very  malarious. 
It  is  therefore  important  that  the  human  sources  of 
infection  should  be  known. 

In  a  country  where  malaria  is  prevalent,  those  liable 
to  attack  may  be  divided  into  two  main  classes,  both 
consisting  of  persons  who  have  not  acquired  immunity 
by  previous  attacks  of  malaria  : — 

(i)  Children,  native  and  European,  will  be  liable  to 
harbour  the  parasites,  as  there  is  no  hereditary  immunity. 


PREVENTION    OF   MALARIAL    FEVER  73 

There  may  be  some  hereditary  tolerance.  AduUs  who 
have  hved  for  a  long  time  in  the  country  will  have 
acquired  some  immunity  and  therefore  will  not  com- 
monly harbour  parasites. 

(2)  Susceptible  adults,  European  and  native,  are  those 
who  have  lived  long  in  a  non-malarial  country,  and  are 
therefore  not  immune.  Either  of  these  classes  in  a 
malarial  country  may  serve  as  the  starting-point  of  fresh 
cases  by  infecting  the  mosquitoes. 

The  first  class  are  of  most  importance  in  fixed  settle- 
ments and  also  in  infecting  travellers  passing  through 
a  country. 

The  second  class  are  of  special  importance  in  opening 
up  uninhabited  country  ;  in  mines,  plantations,  and  road 
or  railway  construction. 

With  large  bodies  of  men  outbreaks  may  originate 
from  infection  acquired  from  native  children,  or  may  be 
imported  by  some  of  the  adults  joining  such  a  force  as 
these  may  harbour  the  parasites.  When  malaria  is  once 
introduced  amongst  such  a  body  of  men,  each  case  serves 
to  infect  the  mosquitoes,  and  these  in  turn  infect  other 
men  till  all  susceptible  members  of  the  gang  are  attacked. 

In  travelling  through  a  malarial  country  an  endeavour 
should  be  made  to  avoid  being  bitten  by  mosquitoes  by 
the  free  use  of  mosquito  netting,  by  avoidance  of  places, 
particularly  for  camps,  where  the  mosquitoes  are  likely 
to  be  infected,  and  by  the  use  of  quinine.  The  common 
practice  in  travelling  by  river  of  tying  up  for  the  night 
near  a  native  village  should  be  discontinued.  In  a  town, 
settlement,  or  permanent  camp,  more  radical  measures 
should  be  instituted. 

The  policy  of  isolation  cannot  be  carried  out  fully  by 
missionaries ;  or  by  persons  in  charge  of  labour  on 
extensive  works,  and  in  countries  where  native  races 
are  civilized  it  does  not  improve  or  aim  at  improving 
the  sanitary  condition  of  the  place,  nor  at  reducing  the 
heavy  infantile  mortality  always  met  with  in  native  races 
in  a  badly  malarial  country. 


74  TROPICAL   MEDICINE   AND   HYGIENE 

Universal  administration  of  quinine  to  all  persons  in 
whose  blood  there  is  evidence  of  malarial  infection  to 
be  of  value  must  be  continuous ;  it  is  expensive  and 
except  with  persons  under  strict  control  impracticable. 
With  troops,  gangs  of  European  workmen,  and  school 
children,  it  can  be  carried  out  successfully,  sometimes 
also  in  small  villages  or  settlements. 

With  large  stations  the  most  satisfactory  results  are 
obtained  by  diminishing  the  number  of  the  definitive 
hosts,  anophelines.  The  most  vulnerable  period  in  the 
life-history  of  these  insects  is  in  their  larval  stage.  This 
is  always  passed  in  water.  A  somewhat  detailed  know- 
ledge of  the  class  of  breeding-place  for  the  species  that 
carry  malaria  in  each  place  is  required  for  effective  and 
economical  work  in  this  direction.  As  these  places  differ 
for  each  species  of  mosquito,  without  detailed  knowledge 
money  will  be  wasted  and  the  results  cause  disappointment. 

Measures  that  would  be  well  adapted  in  places  where 
the  malaria  is  carried  by  Pyretoplionis  costalis  would  be 
unnecessary,  useless  and  extravagant,  say  in  Malaya,  as 
they  would  only  result  in  the  destruction  of  the  harmless 
Myzomyia  rossi,  and  would  be  insufficient  and  unsuitable 
in  places  where  the  carrier  was  M.  fnnesta  or  M.  ciUici- 
facies. 

M.  funesta,  Anopheles  inaciilipennis,  P.  costalis  and  Cellia 
argyrotarsus  or  alhiuianiis,  are  the  important  carriers  of 
malaria  in  Southern  Europe,  Tropical  West  Africa,  and 
Tropical  America,  respectively.  In  Asia,  M.  willinori, 
M.  culicifacies  and  M.  karwari  are  proved  carriers,  but 
many  others,  such  as  C.  koclii,  A.  treacheri,  &c.,  are  prob- 
ably important  carriers.  Of  these  there  is  some  simi- 
larity in  the  habits  of  A.  niacnlipennis,  P.  costalis  and  C. 
argyrotarsus,  and  also  C,  kochi,  a  suspected  carrier.  They 
all  breed  in  roadside  pools,  small  collections  of  water, 
in  stagnant  water,  sometimes  very  foul,  and  occasionally 
in  collections  of  water  in  artificial  receptacles. 

Their  favourite  breeding  places  vary.  In  Asia  the 
anopheline   that   is   mainly  found   in   such    situations  is 


SURFACE    DRAINy\(iE  75 

M.  rossi  which  practically  docs  not  carry  malaria.  Asiatic 
towns,  therefore,  are  relatively  free  from  malaria,  whilst 
in  African  and  South  American  towns  a  much  more 
complete  drainage  would  be  required  to  have  any  material 
effect  on  the  amount  of  malaria. 

M.  ivillrnori,  M.  culicifacies,  and  M.  karwari,  all  stream 
breeders  in  open  country,  are  good  carriers. 

M.  funesta  in  Africa  and  many  of  the  important  Asiatic 
malaria-carrying  mosquitoes  {e.^.,  M.  culicifacies)  are  only 
found  in  clear  water  which  is  usually  in  motion  and  in 
grass-grown  edges  of  springs,  streams  and  rivers.  They 
cannot  thrive  in  stagnant  waters.  They  may  be  found 
in  marshes,  but  only  when  the  water  is  kept  fresh  by 
springs,  or  streams,  and  during  seasons  when  there  is 
a  heavy  rainfall. 

The  problems  to  be  dealt  with  will  vary  according 
to  the  breeding-places  of  the  dangerous  mosquitoes. 
Where,  as  in  a  settlement,  there  is  artificial  interference 
\vith  the  natural  drainage,  as  in  making  roads,  fords 
and  bridges,  the  problem  is  more  complicated.  In  such 
places  frequently  hollows  have  been  left  in  house  building 
or  road  making,  and  there  are  trenches  at  the  roadsides, 
or  for  local  drainage  which  must  also  be  dealt  with.  In 
the  East  such  places  are  of  little  importance  in  the 
towns,  whilst  in  Africa  they  are  of  vital  importance. 

As  a  general  principle,  superficial  drainage  must  be  so 
complete  that  even  during  the  rains  the  shallow  pools 
formed  only  last  for  a  day  or  two,  or  at  any  rate  not  for 
more  than  a  week,  and  drains  must  be  so  graded  that 
with  heavy  rains  they  are  well  flushed  and  no  pools  are 
left  of  any  depth  in  the  intervals. 

In  all  places  where  there  is  a  hill  at  the  back  of  a  settle- 
ment a  well-devised  intercepting  drain  must  be  arranged 
along  the  base  of  the  hill  so  that  fiooding  from  the  hill 
sides  will  be  avoided.  This  hill  water  is  the  main  cause 
of  the  constant  high  level  of  subsoil  water;  the  rain 
actually  falling  on  the  area  of  the  settlement  is  com- 
paratively unimportant.     In  low-lying  land,  as  in  many 


76 


TROPICAL   MEDICINE   AND   HYGIENE 


of  the  flat  lands,  rich  alluvial  soil  on  the  coast  or  near  the 
mouths  of  the  rivers  where  the  water  is  tidal,  banks  and 
intercepting  trenches,  draining  by  self-acting  sluice-gates 
during  low  tides,  will  also  be  required. 


Quajvtitiea\£artiiymrk  -10  ct. 
lABr 


\  Brick 

SHI  Mortar 

^Sl  Concrete^ 

Wm^art/vl-muiff 

'?^  Limit  £occa*-cctucirv 


Sides  of  aJL  the^ 
above'  sections  can- 
JiOIE  "^  *^  heightened-  by 
addinff  bricks  on 
end  or  side'. 


SCALE  /  =  /2 


Fig.  25. — Sections  of  Drains.     Quantities  estimated  as  in  the  Malay 
Peninsula,  by  Mr.  W.  J.  Kenny. 


Such  drainage  is  necessary  for  agricultural  purposes,  and 
the  drainage  required  for  rubber  growing  or  sugar  plan- 
tations, as  long  as  the  drains  are  kept  clear,  is  ample  to 


SURFACE    DKAINAGE  TJ 

render  such  places  healthy,  if  care  is  taken  that  the  drains 
themselves  are  not  suitable  for  breeding-places. 

The  history  of  plantations  in  the  past  is  instructive. 
In  the  early  history  there  is  a  serious  amount  of  malaria 
before  the  drainage  is  complete;  whilst  the  estate  is 
flourishing  and  kept  in  good  order  no  malaria  or  very 
little ;  but  when  the  estates  are  abandoned  or  neglected, 
and  the  drains  are  sedge  grown,  blocked  or  partly  broken 
down,  they  become  intensely  malarial  for  any  remaining 
inhabitants. 

The  class  of  drains  employed  in  any  place  is  mainly 
dependent  upon  the-  amount  of  money  that  can  be 
devoted  to  the  purpose.  Earth  drains  suffice,  but  require 
much  continued  expenditure  in  upkeep  and  repairs,  whilst 
constant  supervision  is  required.  Wherever  there  is 
much  flushing  or  scouring,  brick  or  cement  open  drains 
are  absolutely  essential. 

All  open  drains  should  be  V-shaped  in  section,  so  that 
a  small  amount  of  water  will  suffice  to  flush  them  and 
little  water  can  accumulate  in  the  narrow  bottom  of  the 
drains.  The  large  drains  should  be  similar  in  section, 
but  the  bottoms  may  be  flat  or,  better,  rounded.  Half 
pipes  or  stone  pipe  inverts  make  excellent  bottoms  for 
such  drains  (fig.  25). 

As  temporary  methods  the  destruction  of  larvae  by 
larvicides  is  of  great  use,  but  should  not  be  relied  on 
for  permanent  purposes.  Crude  petroleum  or  other  oils 
rapidly  destroy  larvae,  as  the  films  formed  on  the  surface 
prevent  the  larvcC  getting  air  through  their  respiratory 
syphons.  Unfortunately  it  also  kills  off  fish  and  many 
forms  of  life,  and  the  water  becomes  putrid  and  often- 
sive.  Something  may  be  hoped  for  from  some  of  the 
native  fish  poisons.  These  usually  belong  to  one  or 
other  of  the  species  Derris.  The  roots  are  crushed 
and  thrown  into  the  water,  and  the  milky  fluid  from  the 
fresh  roots,  even  in  minute  quantities  and  much  diluted, 
will  destroy  the  larvae,  and  for  small  collections  of  fluid, 
cesspits,  &c.,  is  highly  effective,   and  though  killing  off 


yS  TROPICAL   MEDICINE   AND   HYGIENE 

most  forms  of  animal  life  does  not  render  the  water  as 
putrid  or  offensive  as  the  use  of  oils.  Where  fish  are 
present  these  would  be  destroyed,  and  therefore  this 
method  is  not  advisable  in  larger  collections  of  water. 
Many  fish  feed  on  mosquito  larvae,  and  are  one  of  the 
important  enemies  of  mosquitoes.  Amongst  these  the 
Cyprinodontidce  are  of  special  importance.  The  small 
•fish  known  locally  as  "  Millions  "  in  Barbados  belong 
to  this  family,  either  Poecilia  or  Gambiisia,  and  are  by 
some  believed  to  be  the  reason  for  the  absence  of 
anophelines  from  that  island.  Even  worse  enemies  are 
the  larvae  of  some  of  the  Dragon-flies  {Agrionidce)  ;  these 
breed  in  similar  places  to  mosquito  larvae,  and  live  on 
them  to  a  large  extent. 

In  countries  where  the  dangerous  mosquitoes  are  stream 
and  river  breeders,  drainage  is  of  little  value  and  the  use 
of  larvicides  impracticable.  Much  can  be  done  by  remov- 
ing sedges,  reeds  and  grasses  growing  into  the  streams, 
keeping  the  banks  clear,  and  removing  obstructions  in 
the  river  bed  or  sides,  so  that  a  uniform  flow  of  water  is 
maintained  in  the  part  of  the  stream  in  the  vicinity  of 
the  settlement,  and  the  larvae  are  washed  further  down 
stream. 

The  selection  of  the  site  for  a  settlement  is  a  most  im- 
portant matter.  In  the  case  of  small  stations  on  unsuit- 
able sites  it  will  often  be  found  better  to  abandon  the 
station  than  to  attempt  to  render  it  healthy.  A  suitable 
site  is  one  in  which  there  is  natural  drainage  or  in  which 
there  is  sufficient  slope  to  allow  of  easy  drainage.  Small 
streams  and  springs  are  sources  of  danger.  If  a  settle- 
ment be  made  on  a  river  the  side  selected  should  be 
that  where  there  are  no  shallow  shoaling  edges ;  these 
are  much  more  liable  to  be  overgrown  and  the  current 
is  slacker.  In  the  selection  of  sites  for  settlements, 
marshes  or  low-lying  ground  must  be  avoided  and  any 
site  in  proximity  to  such  places.  The  effect  of  culti- 
vation is  twofold.  In  the  first  place,  the  clearing  of  the 
ground  and  the  removal  of  dense  jungle  renders  the  air 


SELECTION    OF   SITES  79 

drier  and  admits  much  more  sunlight.  Clearing  alone 
will  suffice  for  the  extirpation  of  some  mr)squitoes  : 
those  that  frequent  jungle,  which  are  mainly  Aidiiia,  but 
in  a  few  instances  dangerous  Anopliclind.  Clearing,  if 
thorough  as  regards  the  low  jungle,  will  cause  a  great 
diminution  in  the  number  of  these  jungle  mosquitoes  or 
their  complete  disappearance,  even  if  the  tall  trees  are 
left.  On  the  other  hand,  if  suitable  breeding-places  are 
left,  such  as  sedgy  streams,  other  mosquitoes  may  become 
much  more  abundant,  and  these  may  include  dangerous 
anophelines,  such  as  M.  wlllniori,  karwari  ?ind  christopJicrsi, 
in  Asia,  or  M.  fniicsta  in  Africa,  or  C.  argyrotarstis  in 
America.  Clearing  without  drainage,  therefore,  may  sub- 
stitute one  dangerous  mosquito  for  another,  though,  on 
the  whole,  it  is  beneficial,  as  the  exposed  ground  dries 
more  readily  in  dry  weather  and  is  more  likely  to  be 
thoroughly  flushed  in  heavy  rains  than  uncleared  ground. 
If  combined  with  drainage,  and  if  the  drains  are  kept 
clear,  or  even  moderately  clear  and  free  from  sedges,  it 
is  usually  effective.  The  better  the  drainage  required  for 
the  special  form  of  cultivation,  the  more  will  the  healthi- 
ness of  the  district  be  improved.  Rubber  plantations 
require  deep  drainage,  and  the  only  breeding  places  pos- 
sible in  such  a  plantation  are  in  the  drains  or  in  the 
areas  beyond  the  plantation  into  which  the  water  may 
be  discharged. 

Sugar-cane  is  also  satisfactory,  for  though  the  drainage 
required  is  not  so  deep,  the  surface  of  the  ground  is  so 
thoroughly  worked  up  that  water  soaks  into  the  soil  and 
no  pools  are  left  for  more  than  a  short  period,  even 
during  a  rainy  season.  Maize  also,  for  similar  reasons, 
is  a  satisfactory  crop.  Rice,  on  the  other  hand,  is  an 
unsuitable  crop  in  a  malarious  tropical  country,  as 
during  the  early  stages  of  cultivation  the  earth  is  covered 
with  water.  Wet  rice  cultivation  should  not  be  allowed 
within  one  mile  of  any  settlement,  as  many  anophelines, 
some  harmless  and  others  good  carriers  of  malaria,  may 
breed  in  the  paddy  fields. 


8o  TROPICAL   MEDICINE   AND   HYGIENE 

In  many  forms  of  cultivation  irrigation  is  employed, 
either  as  in  the  paddy  fields  where  the  ground  is  flooded 
and  remains  flooded,  which  is  very  dangerous,  or  by 
conveying  water  through  a  series  of  superficial  trenches 
to  keep  the  subsoil  moist.  In  this  form  of  irrigation, 
which  is  used  for  gardens,  vegetables,  &c.,  the  risk  is 
slight  if  the  irrigation  be  intermittent,  the  drains  kept 
clear  and  so  graded  that  water  does  not  remain  in  any 
part  of  the  trench  for  more  than  one  or  two  days. 

It  sometimes  happens,  however,  that  the  water  is  drawn 
from  a  mosquito-breeding  place,  and  then  pupae  may  be 
conveyed  by  the  water  to  the  gardens  in  or  close  to  a 
settlement  and  hatch  out  during  the  period  of  irrigation. 
No  system  of  irrigation  is  safe  unless  well  looked  after 
and  in  which  the  supply  of  water  is  not  so  under  control 
that  it  can  be  rendered  intermittent.  Care  also  must 
be  taken  that  the  overflow  is  conveyed  into  a  definite 
channel,  natural  or  artificial,  and  not  allowed  to  spread 
over  the  surface  of  adjoining  land,  as  though  the  culti- 
vated area  may  be  free  from  anophelines  the  surrounding 
district  may  be  made  worse. 

It  is  important  to  have  both  the  coolie  lines  and  the 
European  quarters  at  some  distance  from  each  other,  so 
that  infected  anophelines  cannot  readily  pass  from  one 
to  the  other,  and  that  both  should  be  well  in  the  culti- 
vated, cleared  and  drained  area  where  the  number  of 
anophelines  has  been  reduced. 

Wet  methods  of  culitivation,  such  as  that  required  for 
rice  growing  or  such  cultivation  as  requires  an  extensive 
system  of  artificial  irrigation,  is  not  permissible  in  the 
vicinity  of  a  station. 

In  all  procedures  for  the  reduction  in  the  amount  of 
malaria  it  must  be  remembered  that  partial  measures  are 
of  value  and  will  result  in  a  diminution  in  the  amount 
of  malaria,  but  that  the  more  complete  the  methods  are 
the  more  successful  they  will  be.  The  exact  measures 
adopted  require  an  exact  knowledge  of  the  local  con- 
ditions and  of  the  normal  and  exceptional  breeding-places 
of  the  local  species  of  anophelines. 


ENDKMIC    INDKX    IN    MALARIA  8 1 

Estimation  of  the  prevalence  of  malaria  in  any  place 
is  important,  as  on  the  variations  in  this  prevalence  the 
test  of  the  success  or  otherwise  of  anti-malarial  measures 
must  be  judged,  and  the  justilication  for  the  cost  of 
the  works  and  the  advisability  of  European  occupation 
determined. 

There  are  few  diseases  which  affect  the  working  strength 
of  labour  gangs  so  much  as  malaria.  Attacks  of  the 
disease  in  persons  once  infected  are  frequent,  debility 
results,  and  much  sick  leave  is  required,  so  much  so  that 
a  double  staff  of  Europeans  has  to  be  provided.  The 
mortality  is  high,  though  relatively  not  so  high  as  the 
morbidity.  Amongst  natives,  the  infantile  mortality  is 
very  high  in  any  place  where  malaria  is  prevalent. 

The  usual  term  used  to  indicate  the  prevalence  of 
malaria  is  endcuiic  index.  No  satisfactory  single  word 
has  been  devised.  The  determination  of  the  endemic 
index  may  be  made  in  many  ways  : — 

{A)  Determination  of  the  proportion  of  the  inhabitants 
infected  with  the  parasites. 

This  requires  the  division  into  age  groups,  as  in  malaria 
inimnnity  is  slowly  acquired  by  repeated  attacks.  Examina- 
tion of  the  blood  of  adults,  therefore,  in  a  very  badly 
malarial  place  would  show  no  parasites,  i.e.,  if  examina- 
tion were  confined  to  adults  the  endemic  index  would 
appear  to  be  O. 

Exarniuation  of  the  children  who  have,  when  born, 
no  immunity  will  show  a  higher  index.  In  a  very  badly 
malarial  place  some  children  in  the  first  six  months  of 
life  will  be  found  to  be  infected ;  in  the  second  six 
months  the  proportion  with  parasites  rapidly  rises,  and 
in  the  second  to  fourth  years  the  great  majority,  over 
80  per  cent.,  may  show  evidences  on  blood  examination 
of  malarial  infection.  After  the  fifth  year  the  propor- 
tion showing  such  evidences  rapidly  diminishes,  so  that 
in  a  very  malarial  place  the  majority  may  acquire  im- 
munity by  the  sixth  year  or  even  earlier,  and  practicallv 
all  before  the  tenth  year.  In  a  less  malarial  place  the 
6 


82 


TROPICAL   MEDICINE   AND    HYGIENE 


proportion  free  from  evidence  of  malaria  in  the  first  five 
years  of  life  will  be  higher,  and  in  the  second  five  years 
lower,  and  in  places  w^here  the  amount  of  malaria  is  not 
great,  or  where  infection  does  not  occur  during  part  of 
the  year,  as  in  temperate  climates,  a  large  proportion  of 
the  population  may  never  acquire  immunity. 

A  common  method  for  determining  the  endemic  index 
is  to  determine  the  proportion  of  children  aged  lo  years 
or  less  in  whose  blood  evidence  of  malaria  is  found. 
This  age  is  rather  high,  and  the  results  differ  if  a  large 


12     5        10       15       20      25      30      35     40 


Fig.  26. Negroes  (Native  Africans). — Hausa  and  Yomba  Children, 

320;  Hausa  Adults,   loo.     Compiled  from  Official  Report,  Lagos,  of  W.  H. 
G.  H.  Best. 


proportion  are  over  or  under  5  years  of  age.  In  the 
same  country  the  results  would  therefore  appear  to  vary 
greatly  according  to   the  ages  of  the  children  examined 

(fig.  26). 

The  best  method  would  be  to  determine  the  age  at 
which  the  largest  proportion  of  children  are  found  to  be  in- 
fected. Thus,  if  the  largest  proportion  of  infected  children 
were  under  2  years  old,  it  would  indicate  a  higher 
endemic  index  than  if  the  maximum  proportion  was  at 
5,  and  still  more  if  the  maximum  was  in  children  aged  10. 
A  low  rate  in  persons  over   10  years  of  age  in  a  place 


ENDEMIC   INDEX    IN    MALARIA 


H3 


where  malaria  is  known  to  occur  suggests  a  lii^h  cnrlemic 
index. 

{B)  Prevalence  of  enlarged  spleen.  This  test  has  fallen 
undeservedly  into  disuse  on  account  of  the  manner  in 
which  it  was  at  one  time  abused  in  India  by  the  laity  as 
well  as  by  medical  men.  With  limitations  it  is  of  con- 
siderable value.  The  limitations  are  :  (i)  That  other 
diseases,  such  as  kala-azar,  trypanosomiasis,  &c.,  are  also 
causes  of  enlargement  of  the  spleen,  and  that  therefore, 
where  these  diseases  are  prevalent  the  value  of  the  test  is 
greatly  reduced  ;  and  (2)  that  the  examinations  should  be 
limited  to  children,  as  in  adults  of  many  races,  Indians, 
&c.,  chronic  enlargement  of  the  spleen,  whether  as  a 
result  of  early  infection  of  malaria  or  not,  persists 
throughout  adult  life,  and  may  even  increase. 


vlar's"     '2     5        10       15       20      25      30 

a     90 

CO 

^?70- 

ss 

I 

■5  Q.  60  - 

'\ 

\ 

0)   1- 

M)«  on -J 

!s 

L 

CUJ 

1 

^-. 

S      2°~ 

'  IV 

'\ 

Q.         'Oil 

1 

^vj 

Fig.    27. Negroes  (Native  Africans),   in  a  most  malarial   district 

in  Central  Africa.      Residence  required  for  probable   infection  with   malaria, 
under  six  weeks.      (1899.) 

Native  African,  in  less  malarial  district.     Residence  for  one  year 

does  not  render  infection  certain. 


With  negro  races  the  results  obtained  by  the  spleen 
test  are  of  high  value.  With  other  races  only  the  ex- 
aminations made  of  children  up  to  15  are  valuable 
(tig.  27).  The  advantages  of  the  method  of  spleen 
examination    are   that  :    (i)  There    is   less    opposition    to 


84  TROPICAL   MEDICINE    AND    HYGIENE 

palpation  of  the  abdomen  in  children  than  to  blood 
examination ;  (2)  that  the  examinations  can  be  made 
more  quickly  than  the  examination  of  blood  for  parasites, 
and  far  more  quickly  than  differential  leucocyte  counts  ; 
(3)  that  with  little  training  moderately  reliable  results  may 
be  obtained  by  trustworthy  men  with  no  medical  educa- 
tion ;  (4)  that  the  condition  of  the  spleen  does  not  vary  so 
rapidly  as  the  number  of  parasites  in  the  blood.  Thus  a 
spell  of  cold  or  wet  weather  will  often  result  in  an  increase 
in  the  proportion  of  persons  in  whose  blood  the  parasites 
are  sufficiently  numerous  to  be  readily  found,  whilst  the 
probabilities  of  a  new  infection  are  not  affected  by  such 
meteorological  changes.  The  size  of  the  spleen  is  affected 
by  such  changes  to  a  very  slight  extent. 

(C)  The  period  of  residence  or  exposure  required  in 
the  average  European  or  other  susceptible  person  before 
an  attack  of  malaria  develops  is  a  very  fair  measure  of 
the  endemic  index.  Most  Europeans  are  able  to  give 
fairly  definitely  the  period  that  elapsed  between  their 
arrival  in  the  country  and  the  onset  of  their  first  attack 
of  fever.  The  first  attack  of  fever  is  usually  a  marked 
one,  and  comparatively  few  errors  in  diagnosis  are  made 
with  this  attack  in  a  malarious  country.  The  shorter  the 
period  of  average  residence  required,  the  higher  the 
endemic  index. 

The  period  mentioned  includes  the  period  of  incuba- 
tion, usually  ten  to  fourteen  days.  The  first  attack  of 
fever  is  usually  a  severe  one,  but  it  must  be  remembered 
that  many  Europeans  are  inclined  in  a  malarial  country 
to  call  any  illness  from  which  they  suffer  "fever."  This 
reduces  to  a  small  extent  the  value  of  the  method. 

(D)  The  proportion  of  bodies  showing  past  or  present 
evidence  of  malaria  in  the  shape  of  malarial  pigment 
deposits  is  only  of  value  in  places  where  post-mortem 
examinations  can  be  made  (fig.  28). 

(£)  The  number  of  anophelines,  especially  of  those 
belonging  to  species  known  to  carry  malaria,  is  of  great 
importance.     A  large  number  indicates  the  possibility  of 


ENDEMIC   INDEX    IN    MyM.ARIA 


85 


a  high  endemic  index  in  the  place,  if  suflicient  oppor- 
tunities for  the  infection  of  these  mosquitoes  exist.  If 
the  proportion  of  the  anophehnes  found  to  be  infected 
is  large  it  indicates  a  high  endemic  index  :  but  the 
absence  of  infected  mosquitoes,  even  when  a  large 
number  are  examined,  especially  of  the  mosquitoes 
caught  in  European  houses,  is  quite  compatible  with  a 
high  endemic  index.  In  fact  this  test  is  a  better  indi- 
cation   of  the   present   danger    in    a    certain  house   than 


Age  in      , 
Years 

2     5        10       15      -20      25      30      35      40             50             60  0vor60 

c 

B 

«     80  - 

^ 

N.  ^ 

A 

«  §  70  - 

[ 

V 

V 

oco 

\ 

-o50  - 

o2 

V 

N 

B  M)^° 

\ 

S     20  - 
i"       in 

, 

^ 

^^ 

Fig.  28. Negroes  (Native  Africans),  compiled  horn  fost-morteni 

examinations  in  British  Guiana,  1893- 1895.  The  line  commences  at 
one  month,  no  pigmentation  being  found  earlier.  The  next  point  is 
"  under  six  months." 


of  a  high  malarial  index  of  a  village  or  country.  It  also 
applies  only  to  the  time  at  which  the  examination  was 
made,  for  if  susceptible  mosquitoes  are  present  in  abund- 
ance the  introduction  of  one  or  two  persons  in  whose 
blood  gametocytes  are  present  may  lead  to  the  infection 
of  a  large  number  of  anophelines  and  transform  a  place 
from  one  with  a  low  to  one  with  a  high  endemic  index. 

Much  careful  work  is  yet  required  to  ensure  uniform 
results  for  prophylactic  measures  cheaply.  Enquiries 
must  include  (i)  the  determination  of  the  dangerous 
and  harmless  species  of  anophelines  present  ;    (2)  their 


86  TROPICAL   MEDICINE   AND   HYGIENE 

breeding  places;  (3)  the  endemic  index  of  malaria  as 
determined  by  various  methods,  and  with  a  sufficient 
number  of  observations  to  diminish  the  mean  probability 
of  statistical  error. 

Ross  uses  a  modification  of  Poisson's  formula  by 
Professor  Karl  Pearson,  and  illustrates  the  use  by  deter- 
mination of  the  percentage  error  in  the  application  of 
the  spleen  test  in  a  village  as  follows  : — 

Let  N  be  the  total  number  of  children,  n  the  number 
examined,  and  x  the  number  with  enlarged  spleens.  --  X 
100  will  be  the  percentage  proportion  with  enlarged 
spleens  of  those  examined  =  the  spleen  rate. 

We  cannot  conclude  that  the  same  rate  will  hold  for 
the  entire  number  N.  Let  e  denote  the  probable  per- 
centage error  : — 

n      \l  n  kJ  N  —  I 

In  the  instance  Ross  gives  ("  Report  on  the  Preven- 
tion of  Malaria  in  Mauritius ")  200  out  of  800  children 
in  a  village  were  examined,  and  the  probable  error  was 
+  8*65,  so  that,  as  regards  merely  the  statistical  error, 
the  rate,  if  half  the  children  examined  were  found  to 
have  enlarged  spleens,  would  be  for  the  whole  infantile 
population  between  58*65  and  4i'35,  i.e.,  50  +  8"65. 


«7 


CHAPTER    VII. 
BLACKWATER   FEVER. 

Throughout  Tropical  Africa,  hsemoglobinuria  is  one 
of  the  most  important  of  the  diseases  that  cause  the 
excessive  mortality  •  amongst  Europeans,  and  in  the 
numerous  enquiries  made  into  the  causation  of  this 
disease  by  various  observers  the  possibility  of  the  active 
causal  agent  being  a  piroplasma  has  been  fully  con- 
sidered. No  piroplasma  has  been  found,  and  as  com- 
petent observers  have  made  the  examinations,  if  it  is  due 
to  such  a  parasite  it  must  be  to  one  so  small  that  it  has 
escaped  detection.  The  distribution  of  the  African 
Ixodidae  does  not  support  the  hypothesis  that  it  is  a 
disease  carried  by  ticks,  as  it  probably  would  be  if  it 
were  a  piroplasmosis. 

Blackwater  Fever  (Endemic  Haemoglobinuria). — This 
disease  is  essentially  an  acute  haemolysis,  usually  of  short 
duration,  terminating  in  recovery,  unless  complications, 
such  as  suppression  of  urine,  occurs.  Death  also  occurs 
from  the  intensity  of  the  anaemia  induced.  The  causation 
is  not  definitely  known. 

Geogvaphical  Distribution. — It  is  a  common  disease 
throughout  the  whole  of  tropical  Africa  and  occurs  in 
subtropical  South  Africa.  It  occurs  frequently  in  Assam 
and  some  of  the  Indian  terais  ;  isolated  cases  occur  in 
South  America,  Malay,  and  the  islands  in  the  Indian 
Ocean,  the  Solomon  Islands,  C^^prus  ;  and  epidemics  have 
occurred  in  Greece,  Sardinia,  &c. 

The  clinical  covu'se  of  the  disease  can  be  conveniently 
divided  into  live  stages  : — 

(i)  Prodromal  stage,  usually  febrile. 


88-  TROPICAL   MEDICINE   AND    HYGIENE 

(2)  Onset  of  characteristic  symptoms — haemoglobinuria 
and  jaundice. 

(3)  Continuance  and  disappearance  of  the  haemoglo- 
binuria. 

(4)  Secondary  pyrexia. 

(5)  Convalescence. 

(i)  The  prodromal  stage  is  usually  mistaken  for  an 
ordinary  attack  of  malaria,  and  in  cases  where  blood 
examination  has  been  made  in  this  stage  malaria  parasites 
— subtertian  in  most  instances — have  been  found.  The 
fever  need  not  be  severe,  in  fact  the  patient  is  often  able 
to  travel  and  walk  about,  and  is  rarely  so  ill  as  to  be 
rigidly  confined  to  bed.  Occasionally,  but  very  rarely, 
no  symptoms  at  all  are  observed,  and  the  prodromal  stage 
may  then  appear  to  be  absent. 

(2)  The  onset  is  sudden  and  frequently  marked  by  a 
severe  rigor  and  high  temperature,  and  pain  usually  in 
the  region  of  the  liver,  but  sometimes  in  the  back.  This 
pain  may  be  very  severe,  or  may  be  little  more  than 
discomfort  ;  in  the  majority  of  instances  it  is  transient. 
The  patient  is  seized  with  an  urgent  desire  to  micturate, 
and  finds  his  urine  to  be  of  a  deep  black  colour,  some- 
times only  of  a  deep  brown,  methasmoglobin  in  that  case, 
and  not  haemoglobin,  being  passed. 

The  urine  when  passed  is  a  valuable  guide  to  the  dura- 
tion of  the  acute  disease.  If  methaemoglobin  alone  is 
passed  the. attack  is  only  slight,  but  may  be  followed  by  a 
more  serious  relapse.  If  much  dilution  is  required  to 
render  the  urine  transparent,  a  severe  attack  may  be 
anticipated. 

An  examination  of  the  second  urine  passed  should  be 
made.  If  the  first  only  be  examined,  confusion  might 
occur,  as  this  is  diluted  by  the  urine  that  had  previously 
accumulated  in  the  bladder.  From  the  examination  of 
this  second  urine  a  fair  estimate  of  the  duration  of  the 
haemoglobinuric  period  can  usually  be  made. 

(3)  After  the  onset  of  the  haemoglobmuria  urine  is 
secreted  in  much  larger  quantities  than  is  normal,  and 


BLACKWATER    FEVKK  89 

if  abundant  water  be  supplied  either  by  the  moutli,  if 
there  be  little  or  no  vomiting,  by  the  rectum  or  subcu- 
taneously,  the  rate  of  secretion  continues  high  as  long  as 
the  hccmoglobinuria  lasts. 

The  frequency  of  micturition  at  first  is  only  increased 
in  proportion  to  the  amount  of  urine  secreted,  the  bladder 
being  emptied  only  when  distended,  but  later  the  urine 
is  passed  more  frequently,  and  in  small  quantities  only  at 
a  time,  as  the  urine  appears  to  act  as  an  irritant  to  the 
bladder.  Occasionally  there  is  marked  irritability  of  the 
bladder,  and  rarely  retention  of  urine. 

Jaundice  rapidly  develops,  the  conjunctiva  and  skin 
becoming  markedly  yellow\  There  is  no  bile  in  the 
urine,  and  the  stools  are  very  dark,  so  that  the  jaundice 
is  not  obstructive,  and  is  probably  haematogenous.  Con- 
stipation is  usual,  but  is  easily  relieved  by  purgatives. 
These  must  be  used  with  great  caution. 

The  temperature  remains  high  and  there  may  be  hyper- 
pyrexia, but  falls  as  the  haemoglobinuria  diminishes. 
There  may  be  only  the  initial  rigor,  but  frequently  there 
is  more  than  one,  and  sometimes  there  are  several  each 
day.  There  is  always  nausea,  and  frequently  vomiting. 
This  may  be  so  severe  that  the  smallest  amounts  of  food 
or  fluid  are  returned  as  soon  as  they  are  taken.  Very 
rarely  there  is  haematemesis  ;  commonly  there  may  be 
streaks  of  blood  if  the  vomiting  be  violent. 

Hiccough  is  common,  and  may  be  so  incessant  that  it 
becomes  a  source  of  danger  from  the  exhaustion  induced. 
The  prognosis  is  unfavourable  if  there  is  much  hiccough. 
When  only  occasional  it  has  no  prognostic  value.  There 
is  usually  no  pain  after  the  onset,  not  even  headache,  but 
sometimes  there  is  aching  pain  in  the  loins,  and  the 
abdominal  pain  present  at  the  onset  may  recur  and 
become  continuous. 

Most  important  is  the  rapid  development  of  extreme 
anaemia.  The  red  blood  corpuscles  in  the  course  of  three 
da^^s  may  be  reduced  to  1,000,000  or  even  less  per  cubic 
millimetre.      The   remaining    blood    corpuscles   mav   be 


90 


TROPICAL   MEDICINE   AND    HYGIENE 


much  changed,  many  being  mere  shadows  devoid  of 
haemoglobin,  or  appear  fairly  normal  and  above  the 
average  tonicity.  Associated  with  this  anaemia  is  extreme 
debility,  and  violent  palpitations  on  the  slightest  exertion. 
Death  from  syncope  may  occur  during  attempts  at  def^e- 
cation  or  even  micturition. 


TIME 

M 

z 

^ 

E 

M 

E 

M 

E 

^ 

rF 

M 

E 

M 

E 

M 

E 

M 

E 

f; 

E 

U 

E 

M 

E 

1  04 
I03 
102 
10  i 
100 
99 
96 
97 

V 

\ 

\ 

\, 

A 

V 

/N 

V 

/\ 

\^ 

A 

A 

\ 

,     / 

/ 

V 

s 

/\ 

/* 

.n^ 

Y 

V 

/•s 

-"■s:?!^! 

V 

V 

D 

ura 

tio 

;  01 

Na 

]mc 

<)/o 

•//76 

ria 

u 

Fig.    29. — Blackwater  Fever,  mild   attack  ;    haemoglobinuria   less  than 
twenty-four  hours. 


TIME 

M 

E 

M 

E 

M 

E 

M 

E 

M 

E 

M 

F 

M 

E 

M 

E 

M]E 

m|e 

M 

E 

M 

E 

1  04- 

103 

1  02 

101 

100 

99 

9  8 

97 

> 

f 

V 

\ 

A 

r 

•>^ 

> 

'  \ 

\ 

' 

\ 

N 

<1 

V 

'\ 

y 

\ 

I 

V 

\ 

-\ 

k, 

A 

' 

-^ 

s 

S    ( 

/\ 

^ 

/ 

s/' 

\ 

V 

Ou 

•at 

?/> 

I/'. 

fe/ 

70^ 

'0^ 

'" 

Fig.  30.— Blackwater  Fever,  severe  attack  ;  hsemoglobinuria,   two  and 
a  half  days. 


Jaundice,  or  a  yellow  staining  of  the  skin  and, con- 
junctiva, can  be  observed  a  few  hours  after  the  onset  of 
the  haemoglobinuria,  and  deepens  during  its  continuance. 
The  stools  are  always  dark,  the  urine  does  not  contain 
bile,  and  enlargement  or  tenderness  of  the  liver  does  not 
usually   occur.     The   duration    of   this   stage   of    hcemo- 


BLACKWATIiR    FEVIiK  9 1 

glohiniiria  varies  ^n-eally  ;  it  may  last  only  two  or  three 
hours,  but  is  usually  in  a  moderately  severe  case  from 
two  to  three  days.  If  it  lasts  more  than  three  days  tlie 
pro^s^nosis  is  very  ^rave. 

There  is  usually  much  mental  anxiety,  partly  on 
account  of  the  reputation  of  tlie  disease,  but  still  more 
because  of  the  large  amount  of  blood-like  urine  that  is 
being  passed.  The  mental  faculties  are  quite  clear,  and 
beyond  the  debility  there  is  little  actual  distress.  The 
amount  of  haemoglobin  passed  steadily  diminishes, 
though  still  sufficient  to  render  the  urine  opaejue.  The 
last  urine  passed  in  this'  stage  often  contains  no  oxyhaemo- 
globin,  but  methaimoglobin  only,  the  urine  changing 
from  a  red-black  to  a  dark  brown  colour.  As  the  urine 
clears  the  temperature  falls  to  normal  or  subnormal. 
Profuse  sweating  may  occur  several  times  in  one  day. 
The  change  from  the  hasmoglobinuric  period  to  the 
non-haemoglobinuric  is  less  abrupt  than  would  be 
judged  by  mere  superficial  examination  of  the  urine. 
The  haemolytic  process  has  ceased,  and  the  waste 
products  are  being  rapidly  eliminated.  As  the  haemo- 
globin disappears  the  diuresis  diminishes,  so  that  even 
when  abundant  fluid  is  supplied  the  rate  of  secretion 
of  urine  may  fall  to  much  below  normal.  This  is  prob- 
ably merely  the  result  of  the  over-stimulation  of  the 
renal  cells,  so  that  secretion  becomes  slow.  If  any 
urine  at  all  is  passed,  a  fall  in  the  rate  of  secretion  to 
less  than  half  the  normal  is  to  be  expected  and  should 
cause  no  alarm,  though  fluid  must  still  be  supplied  freely. 

The  rate  of  secretion  in  a  favourable  case  soon  increases. 
The  urine  is  clear  and  of  normal  colour,  but  contains 
a  small  amount  of  albumin  and  some  casts.  The  patient 
remains  in  an  extremely  weak  condition,  and  the  anaemia 
may  show  a  slight  increase,  though  the  appearance  of 
the  blood  corpuscles  is  more  natural.  The  temperature 
may  remain  normal  or  commence  to  rise.  After  a  day 
or  two  the  temperature  rises,  usually  above  normal,  and 
for  several  days  there  may  be  irregular  pyrexia,  secondary 


92  TROPICAL   MEDICINE   AND    HYGIENE 

fever.  This  varies  a  great  deal  in  severity.  In  some 
cases  it  is  very  slight,  the  temperature  rising  in  the 
evening  to  ioo°  F.  or  even  less  (figs.  29  and  30).  More 
frequently  the  nocturnal  rises  are  to  101°  and  102°  F., 
the  temperature  falling  nearly  to  normal  in  the  morning. 
In  other  cases  it  is  much  more  severe,  and  occasionally 
there  is  fatal  hyperpyrexia  in  this  stage.  The  usual 
duration  of  this  stage  is  three  to  four  days,  and  it  may 
be  protracted  to  two  or  three  weeks.  The  urine  in  this 
stage  remains  free  from  haemoglobin  and  usually  from 
albumin.  No  further  blood  destruction  is  taking  place, 
and  the  red  corpuscles  and  haemoglobin  are  rapidly  in- 
creasing at  a  rate  sometimes  of  400,000  or  500,000 
corpuscles   per  c.mm,  per  week. 

The  secondary  fever  is  probably  associated  with  the 
metabolic  changes  due  to  the  absorption  and  assimila- 
tion of  some  of  the  waste  products  of  the  haemolysis, 
which  have  been  stored  up  in  various  organs.  The 
icterus  rapidly  disappears.  After  this  secondary  fever 
has  subsided,  convalescence  is  rapid  and  usually  unin- 
terrupted. It  is  highly  exceptional  for  anyone  who  has 
had  blackwater  fever  to  have  any  malaria  attacks  for  a 
prolonged  period;  probably  the  corpuscles  containing 
parasites  are  amongst  the  first  to  be  destroyed,  and  so 
a  "  cure "  of  the  malaria  results.  Sometimes,  as  in  a 
few  cases  in  England,  an  attack  of  malaria  may  occur 
shortly  after  the  blackwater  fever,  though  a  new  infection 
has  not  occurred.  There  are  few  sequelae,  but  the 
debility  and  anaemia  persist  to  some  extent  for  several 
weeks,  and  fatal  cardiac  failure  has  occurred  during 
convalescence. 

If  fluid  is  not  freely  supplied  the  history  is  very 
different.  The  urine,  whilst  still  loaded  with  haemo- 
globin, diminishes  in  amount,  and  vomiting  becomes 
incessant.  The  amount  of  urine  continues  to  diminish 
so  that  only  an  ounce  or  less  is  passed  per  diem.  This 
urine  may  become  free  from  haemoglobin  and  even 
from    albumin,    the   temperature    becomes    normal,    the 


BLACKWATKR    KKVKK  93 

aiiiomiii  diminislics,  but  unless  the  flc^w  of  urine  is 
rapidly  restored  death  is  certain.  This  usually  (occurs 
in  four  or  five  days  or  less,  hut  life  may  be  protracted 
up  to  ten  days.  There  is  no  delirium,  no  convulsions, 
the  mind  is  clear,  and  beyond  headache,  whicli  is  not 
necessarily  severe,  there  are  none  of  the  ordinary  symptoms 
associated  with  renal  disease  or  uraemia ;  vomiting  is 
persistent. 

The  condition  more  closely  resembles  that  due  to 
blockage  of  the  ureters.  This  is  the  commonest  cause 
of  death,  and  if  it  can  be  avoided  the  mortality  from 
blackwater  fever  is  low. 

Duygiiosis. — The  diagnosis  is  made  on  the  character  of 
the  urine.  This  is  dark  red,  practically  black.  If  diluted 
the  red  colour  appears  and  the  urine  is  clear  and  trans- 
parent. On  shaking  the  urine  the  froth  that  forms  on  the 
surface  is  red.  If  allowed  to  stand  a  thick  deposit  soon 
forms,  but  this  is  not  present  when  the  urine  has  been 
recently  passed.  The  deposit  in  the  quite  fresh  urine 
is  scanty.  A  few  casts  may  be  found,  and  later  in  the 
course  of  the  disease  are  more  abundant ;  some  may 
still  be  found  weeks  after  the  urine  is  free  from  albumin. 
These  casts  are  usually  granular  and  contain  bright 
yellow  granules,  not  uric  acid,  similar  to  those  found 
in  the  organs ;  blood  cells  are  rarely  found ;  bladder 
epithelium  may  be  moderately  abundant  after  the  first 
day.  When  the  urine  is  kept  much  deposit  is  formed; 
this  is  composed  usually  of  casts,  coagulum  and  altered 
haemoglobin. 

The  urine  in  paroxysmal  haemoglobinuria  is  similar, 
and  that  disease  w^ould  certainly  be  diagnosed  as  black- 
water  fever  if  a  case  occurred  in  a  blackwater  district. 

If  methaemoglobin  only  be  passed  the  difficulty  in 
diagnosis  is  much  greater,  as  the  brown  urine  is  not  very 
unlike  some  high-coloured  normal  urine,  and  may  be 
mistaken  for  bile-stained  urine.  In  all  cases  if  the  urine 
be  boiled  the  albumin  coagulated  will  be  a  dark  brown 
colour. 


a E  C         I)  El.  F 


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50 


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Fig.  31. — I,  Oxyhemoglobin;  2,  reduced  hEemoglobin  ;  3,  CO.  hsemo- 
globin  ;  4,  methsemoglobin  ;  5,  meihgemoglobin  (after  addition  of  alkali) ; 
6,  alkaline  hsematin  ;  7,  acid  heematin  (etherial  solulion);  8,  hsematopor- 
phyrin  (acid)  ;  9,  hsematoporphyrin  (alkaline)  ;    10,  bilirubin. 


BLACKWATICK    KEVER  95 

The  best  test  to  apply  is  the  speeti'oscopie  one:  Ix^lh 
the  hcemoglobin  ;ind  methcemoglobin  can  be  recognized 
at  once  and  with  certainty  by  the  use  of  any  of  the 
simplest  and  cheapest  direct  vision  spectroscopes.  The 
addition  of  ammonia  will  cause  the  colour  to  change 
so  that  it  becomes  red,  something  like  the  colour  of 
haemoglobin.     (Spectra,  fig.  31.) 

The  absence  or  great  rarity  of  blood  corpuscles  readily 
distinguishes  this  disease  from  any  of  the  forms  of  hasma- 
turia.  Without  microscopic  examination  the  transparency 
of  the  diluted  urine  in  blackwater  fever  distinguishes  it 
from  the  smoky  opalescent  urine  of  haematuria. 

Prognosis. — If  suppression  of  urine  is  averted  the  prog- 
nosis is  good.  Constant  vomiting  and  hiccough  are  of 
unfavourable  import,  and  great  care  has  to  be  exercised 
in  order  to  prevent  syncope  or  cardiac  failure. 

Recurrences  of  the  haemoglobinuric  attacks  sometimes 
occur  at  short  intervals.  Such  a  relapse  may  take  place 
within  twenty-four  hours  of  a  serious  attack,  or  be  delayed 
for  three  or  four  days  ;  it  is  rare  after  that  period.  As 
each  attack  runs  its  own  course,  a  fatal  degree  of  anaemia 
may  be  induced,  and  in  each  attack  there  is  the  same 
liability  to  suppression  of  urine.  A  person  who  has  once 
had  blackwater  fever  appears  to  be  specially  liable  to  it, 
and,  if  he  remains  in  or  returns  to  a  country  where  the 
disease  exists,  will  probably  have  other  attacks.  These 
are  usually  of  a  similar  character  to  his  first  attack,  so 
that,  if  his  first  attack  was  a  mild  one,  subsequent  attacks 
will  probably  be  of  the  same  nature.  Cases  are  known 
of  twelve,  or  even  more,  such  attacks  in  one  person.  If, 
however,  the  first  attack  is  severe,  so  will  subsequent 
attacks  be,  and  few  persons  will  survive  the  third  or 
fourth  attack. 

Pathological  Anatomy. — No  specific  organism  has  been 
discovered.  Malaria  parasites  are  present  when  the  blood 
is  examined  before  the  onset  of  the  disease  ;  thev  dis- 
appear in  these  cases  very  shortly  after  the  onset  of  the 
haemoglobinuria.       In    the    great    majority    of    cases    of 


96  TROPICAL   MEDICINE    AND    HYGIENE 

blackwater  fever,  those  examined  only  after  the  onset  of 
the  disease,  no  parasites  are  found. 

In  fatal  cases  on  microscopical  examination  of  the 
liver  and  spleen,  finely  divided  intracellular  black 
pigment  will  be  found  as  in  recent  malaria.  Frequently 
it  is  not  abundant  enough  to  be  seen  on  inspection 
with  the  naked  eye.  No  parasites  are  found  in  the 
organs,  but  sometimes  pigmented  leucocytes  are  present. 
The  blood  examination  shows  an  increase  in  the  large 
mononuclear  elements,  such  as  is  found  in  malaria,  but 
this  also  occurs  in  other  protozoal  diseases.  No  piro- 
plasmata  have  been  found,  and  the  blood  and  organs 
are  sterile  as  regards  bacteria.  The  organs  show  all  the 
usual  evidences  of  blood  destruction.  In  the  hepatic 
cells,  in  the  convoluted  tubules  of  the  kidneys  and  in 
the  spleen,  are  abundant  deposits  of  haemosiderin,  and 
other  granules  not  pigmented  are  present  which  give 
the  reaction  of  iron  in  inorganic  combination.  This 
evidence  of  blood  destruction  occurs  to  a  less  marked 
extent  in  some  cases  of  malaria  and  in  other  diseases 
attended  with  hzemolysis ;  it  is  marked  in  the  piro- 
plasmosis  of  cattle. 

The  kidneys  in  all  cases  show  casts  in  the  tubules. 
When  death  has  occurred  from  suppression  these  casts 
are  very  numerous.  They  usually  show  evidence  of  the 
presence  of  iron  in  inorganic  combination. 

The  renal  cells,  except  for  the  presence  of  hsemosiderin, 
are  singularly  little  affected.  The  epithelium  is  neither 
detached  nor  necrotic,  but  usually  shows  cloudy  swelling 
and  sometimes  fatty  degeneration.  The  spleen  may  be 
enlarged  or  not.  The  liver,  beyond  the  evidence  of 
haemolysis  and  a  certain  amount  of  cloudy  swelling,  is 
normal  in  appearance  and  structure.  Subserous  haemor- 
rhages and  haemorrhages  into  either  solid  or  hollow 
viscera  are  exceptional. 

Treatment. — No  drugs  have  any  specific  action.  The 
depth  of  colour  of  the  urine  passed  early  in  the  attack 
enables  a  fairly  accurate  estimate  of  the  duration  of  the 


liLACKWATKR    FICVKR 


97 


hiumolysis  to  be  made,  and  tliis  is  not  shortened  bv 
treatment  with  quinine  or  any  other  drug  used.  Though 
we  cannot  deal  with  the  essential  cause,  as  this  is  un- 
known, much  may  be  done  to  avoid  the  main  dangers  of 
the  disease.  The  failure  to  recognize  these  essential 
features  has  caused  the  adoption  of  injurious  measures 
from  time  to  time. 

The  disease  is  not  a  haimorrhagic  one  ;  it  is  a  hccmolytic 
one.  The  actual  disease  occurs  in  the  blood-vessels,  and 
the  red  corpuscles,  once  broken  up,  set  free  the  haemo- 
globin in  the  plasma,  and  there  it  is  injurious  and  has  to 
be  disposed  of.  The  liver  and  other  organs  can  absorb 
it  in  part  only,  but  the  capacity  of  these  organs  is  limited 
and  the  greater  proportion  is  discharged  with  the  urine. 
This  discharge  must  not  be  checked,  but  aided  by  the 
free  supply  of  water.  If  considered  as  haemorrhage  it 
would  be  natural  to  attempt  to  diminish  this  discharge. 
The  patients  themselves  notice  that  they  fill  chamber- 
pot after  chamber-pot  with  what  looks  like  almost  pure 
blood,  and  are  anxious  that  the  loss  should  be  diminished, 
as  they  fear  that  they  are  bleeding  to  death.  The  medical 
attendant  requires  a  firm  faith  in  the  soundness  of  his 
pathological  views,  and  his  action  should  be  to  main- 
tain, and  if  possible  increase,  the  total  amount  of  the 
bloody  urine  discharged.  The  dilution  of  the  urine 
makes  no  obvious  difference  in  its  appearance,  and,  from 
the  point  of  view  of  the  patient  and  his  friends,  the 
measures  that  should  be  taken  will  only  increase  the  loss. 

Free  administration  of  water  is  necessary  to  maintain 
this  flow,  otherwise  there  is  danger  of  such  extensive 
coagulation  in  the  renal  tubules  that  suppression  will 
occur.  The  drugs  used  have  belonged  to  manv  classes. 
Haemostatics,  such  as  ergotin,  have  been  extensivelv  used, 
but  can  have  no  good  effect.  Water  has  been  withheld 
in  order  to  stop  the  loss,  and  this  practice  is  responsible 
for  much  of  the  mortality.  Stimulating  diuretics,  such 
as  turpentine,  have  been  employed,  but  the  haemo- 
globin in  itself  acts  as  so  powerful  a  diuretic  that  it  is 
7 


9o  TROPICAL   MEDICINE   AND   HYGIENE 

unnecessary  to  employ  any  additional  one.  Quinine 
should  not  be  given  unless  parasites  of  malaria  are  found, 
and  even  then  must  be  given  very  cautiously.  Quinine 
in  large  doses  usually  has  no  effect  at  all.  Patients 
may  recover  whilst  taking  60  grains  a  day,  but  it  does 
not  shorten  the  duration  of  the  disease.  In  these  doses 
it  may  increase  the  tendency  to  vomiting,  and  as  in  some 
cases  it  actually  causes  further  haemoglobinuria  it  should 
not  be  given. 

Good  results  are  claimed  for  the  frequent  adminis- 
tration of  boracic  acid  in  solution,  and  of  carbonate  of 
soda  in  moderate  doses,  with  perchloride  of  mercury  in 
minute  doses  frequently  repeated.  They  all  have  the 
advantage  of  increasing  the  amount  of  fluid  taken  by  the 
patient,  and  perchloride  of  mercury  and  carbonate  of  soda 
given  as  in  yellow  fever  seems  to  check  the  vomiting  and 
also  acts  in  the  late  stages  as  a  bland  diuretic.  This 
treatment  has  been  practised  by  Hearsey  with  excellent 
results. 

Carbonate  of  soda...         ...         ...         ...         ...     5  grains. 

Perchloiide  of  mercury    ...         ...         ...         ...     g'j  grain. 

Water  ...  ...  ...  ...  ...  ...     2  oz. 

This  dose  should  be  given  every  hour  till  the  urine  clears. 

The  most  uniformly  successful  treatment  consists  in 
giving  frequent  rectal  enemata,  6  to  8  oz.  at  a  time,  of 
normal  saline  solution  ;  water  alone  is  not  retained. 
These  must  be  repeated  every  hour,  or  every  half-hour, 
according  to  the  severity  of  the  case,  till  the  haemo- 
globinuria ceases.  The  injection  of  large  quantities  of 
sterilized  normal  saline  into  loose  cellular  spaces  such 
as  the  axilla  is  preferred  by  some.  This  cannot  be 
repeated  so  often  as  the  rectal  injections,  but  must  be 
employed  in  cases  where  there  are  both  vomiting  and 
rectal  irritability.  The  great  point  is  to  commence  the 
treatment  early.  If  this  is  done  from  the  onset,  fluid  by 
the  mouth  only  will  suffice,  as  the  vomiting  is  to  a  great 
extent  due  to  the  renal  obstruction,  and  if  the  latter  can  be 
prevented,  or  only  a  few  tubules  are  blocked,  the  vomiting 
can  be  controlled. 


BLACKWATER    FEVEK  99 

If  suppression  has  set  in,  recovery  does  not  take  place, 
but  there  is  just  the  possibiHty  that  the  free  supply  of 
fluids  may  enable  a  sufftcient  flushing  to  take  place  to 
dislodge  some  of  the  casts  and  so  restore  the  functional 
activity  of  a  part  of  the  kidneys.  Alcoholic  stimulants 
are  required  in  all  severe  cases,  but  their  use  should  not 
be  commenced  too  early ;  strychnine  also  should  be 
given. 

The  patient  is  usually  constipated ;  but  active  purga- 
tion is  probably  injurious,  as  it  diverts  into  the  intestine 
the  fluid  that  we  wish  to  pass  through  the  kidneys. 

During  convalescence  good,  easily  digested  food  must 
be  given.  The  digestive  powers  are  usually  good.  The 
bowels  should  be  kept  freely  open  with  salines. 

Iron  and  arsenic  may  be  taken  with  benefit  in  the 
later  stages,  but  there  is  no  advantage  in  giving  them 
early,  as  all  the  actively  metabolic  organs  are  at  that 
time  overloaded  with  iron. 

For  the  secondary  fever  free  purgation  seems  to  be 
the  most  effective.  Quinine  has  no  beneficial  action  and 
may  provoke  a  relapse.  Phenacetin  and  other  anti- 
pyretics are  to  be  avoided  ;  their  action  is  temporary  and 
the  danger  of  cardiac  failure  is  great.  In  hyperpyrexia 
during  this  stage  hot  packs,  cold  packs,  or  cold  baths 
may  be  resorted  to,  but  the  prognosis  is  most  un- 
favourable. 

Relapses  must  be  treated  in  the  same  way  as  the 
primary  attack. 

In  the  exceptional  cases  where  an  attack  of  malaria 
follows  blackwater  fever,  quinine  should  be  given  in 
small  but  gradually  increasing  doses,  commencing  with 
•|-grain  doses. 

Nursing. — Duiing  the  first  day  of  the  illness  the  main 
precaution  to  be  taken  is  to  administer  fluid  frequently, 
so  that  a  considerable  quantity,  at  least  equal  to  that  of 
the  urine  passed,  is  taken.  As  there  is  always  a  tendency 
to  vomiting,  water  must  be  given  in  small  quantities  at 
a  time.     Though  there  is  thirst,  the  amount  of  water  that 


100  TROPICAL   MEDICINE   AND   HYGIENE 

must  be  taken  is  in  excess  of  that  which  the  patient 
desires.  Tepid  sponging  after  the  perspirations  is 
required,  and  great  care  must  be  taken  to  avoid  a  chill. 

This  treatment  must  be  continued  throughout  the 
attack,  but  after  the  first  day,  though  the  muscular 
strength  may  be  considerable,  the  patient  must  not  be 
allowed  to  leave  his  bed  or  even  raise  himself  in  it 
without  assistance.  Any  necessary  movement  must  be 
made  very  slowly.  These  precautions  become  more  and 
more  necessary,  not  only  whilst  the  blackwater  persists, 
but  for  several  days  after.  The  urine  should  be  measured 
after  each  act  of  micturition,  as  it  is  of  the  utmost 
importance  to  obtain  information  as  to  any  diminution 
in  the  rate  of  secretion.  The  vomiting  must  be  checked; 
if  not  restrained  by  sinapisms  or  hot  applications  to  the 
epigastrium,  hypodermic  injections  of  morphia  should 
be  administered  and  all  fluid  given  in  teaspoonfuls  if 
necessary. 

Patients  must  never  be  worried  to  pass  urine ;  they  all 
know  the  danger  of  suppression,  and  any  concern  shown 
by  the  attendant  as  to  this  will  still  further  increase 
their  anxiety.  The  danger  is  suppression,  and  if  no 
urine  is  in  the  bladder  it  can  do  no  good  for  the  patient 
to  attempt  to  micturate.  Retention  does  occur  occasion- 
ally, so  that  if  there  is  undue  delay  in  micturition  the 
abdomen  above  the  pubes  should  be  examined  to  make 
sure  that  the  bladder  is  not  distended. 

If  the  vomiting  cannot  be  checked,  or  sufficient  water 
cannot  be  administered  by  the  mouth,  rectal  injections 
of  normal  saline  solution,  '2  per  cent.,  should  be  given 
hourly. 

As  the  frequent  administration  of  such  enemata 
leads  to  an  irritable  condition  of  the  rectum,  great  care 
is  required.  The  enemata  should  be  given  very  slowly 
and  should  be  at  blood  heat. 

The  blankets  and  clothing  must  be  replaced  by  warm, 
dry  clothing  as  often  as  required.  If  the  tendency  to 
syncope  becomes  marked,  the  lower  end  of  the  bed  must 


]u.ackwati<:k  fever  ioi 

be  niised,  hot-water  bottles  applied  to  the  axilla,  and  the 
legs  bandaged  from  the  feet  upwards,  and  stimulaiits 
given  freely  by  the  mouth,  rectum,  or  by  hypodermic 
injections.  Transfusion  througii  the  veins  has  not  been 
successful,  as  hyperpyrexia  may  occur  either  whilst  hccmo- 
globinuria  is  present  or  afterwards  during  the  secondary 
fever.  The  temperature  should  be  taken  frequently  and 
hourly  when  it  is  above  104°  F.  The  hyperpyrexia  after 
the  urine  has  cleared  is  the  more  dangerous. 

Where  the  patient  is  so  situated  that  there  is  no  skilled 
nursing  available,  the  danger  is  greatly  increased.  Atten- 
tion to  the  general  principles  will  be  of  service,  and  if 
the  patient  has  to  leave  the  bed  his  movements  must  be 
as  slow  as  possible  and  the  head  held  low.  He  must 
crawl,  not  walk  or  hold  himself  upright  under  any  cir- 
cumstances. Any  expressions  of  despondency  must  be 
discouraged.  It  is  useless  to  attempt  to  minimize  the 
danger,  but  the  patient's  courage  must  be  sustained  as 
much  as  possible.  Under  these  circumstances  the  advis- 
ability of  removing  the  pa,tient  to  a  place  where  he  can 
receive  skilled  care  has  to  be  considered.  If  moved  at  all, 
he  should  be  moved  early,  in  the  first  day  of  the  disease. 
Later  the  risk  of  collapse  is  enormously  increased  by  a 
prolonged  journey.  The  risks,  on  the  whole,  of  moving 
are  about  as  great  as  the  advantages  resulting  from  the 
more  careful  attention  would  be. 

If  moved,  the  patient  must  be  carried  in  a  recumbent 
position.  A  hammock  is  as  good  a  method  as  any.  He 
must  be  well  wrapped  up  and  receive  water  frequently 
whilst  on  the  road,  and  food  in  addition  if  the  journey 
be  a  long  one. 

Food  must  be  fluid  and  nutritious  :  it  is  well  digested. 

During  convalescence  great  care  must  still  be  exercised 
both  to  prevent  chill  and  exposure,  for  fear  of  relapses, 
and  to  avoid  over-exertion  or  anything  that  may  throw 
any  strain  on  the  heart,  as  fatal  syncope  mav  occur 
during  this   period. 

Constipation   during  the  early  stages   is   not  of  much 


102      -  TROPICAL   MEDICINE   AND    HYGIENE 

importance  ;  later  the  bowels  must  be  kept  open,  prefer- 
ably by  mild  saline  aperients. 

Etiology.  —  The  true  cause  of  blackwater  fever  is 
unknown.  It  occurs  in  both  sexes,  but  is  not  known 
in  early  childhood.  It  does  occur  in  negroes,  but  not 
in  natives  in  an  area  where  the  disease  is  endemic. 
In  proportion  to  their  numbers  it  is  more  common 
amongst  Europeans  than  amongst  Asiatics.  In  Euro- 
peans it  rarely  occurs  during  the  first  six  months  of 
residence  in  an  endemic  area,  but  after  that  period 
becomes  more  common,  and  is  most  common  in  the 
second  and  third  year  of  residence.  First  attacks  are 
very  rare  after  ten  years'  residence.  A  person  who  has 
not  had  blackwater  fever  in  an  area  in  which  the  disease 
is  endemic  may  have  his  first  attack  after  leaving  that 
area,  sometimes  up  to  six  months  after  leaving  it. 

Generally  speaking,  in  Africa,  it  is  most  prevalent  where 
malaria  is  most  prevalent,  and  by  many  persons  malaria  is 
considered  to  be  essential  for  the  development  of  the 
disease.  As  the  disease  is  not  known  in  some  countries 
where  malaria  is  prevalent,  it  has  either  to  be  assumed 
that  there  is  a  special  variety  of  the  malarial  parasite 
implicated,  or  that  there  is  some  special  condition  under 
which  this  extreme  haemolysis  takes  place.  So  far  all 
experiments  that  have  resulted  in  a  decrease  in  the  amount 
of  malaria  have  been  associated  with  a  reduction  in  the 
number  of  cases  of  blackwater  fever.  This  seems  to 
hold  whether  the  reduction  is  due  to  attacking  the  carriers 
of  malaria,  anophelines,  or  to  steady  administration  of 
quinine. 

No  morphological  differences  have  been  observed  in 
the  malarial  parasites  in  a  malarious  country  where  black- 
water  fever  is  endemic  and  in  malarious  countries  where 
it  does  not  occur.  The  carriers  differ  in  the  different 
countries,  and  in  Africa  Myzoinyiafiinesta  is  the  commonest 
carrier  in  places  where  blackwater  fever  is  prevalent. 

The  special  condition  that  has  been  considered  to  be 
the    immediate    exciting    cause     is    quinine    poisoning. 


BLACKWATER    FEVKK  103 

The  advocates  of  this  hypothesis  contend  that  in  some 
individuals,  after  they  have  been  exposed  to  the  endemic 
influences,  the  blood  is  so  altered  that  quinine  produces 
haemolysis.  There  are  cases  in  which  a  dose  of  quinine, 
even  a  small  one,  may  bring  on  an  attack  of  hsemo- 
globinuria;  this  has  been  proved  in  many  instances. 
There  are  reasons  for  considering  that  this,  though  an 
occasional  cause  of  blackwater  fever,  is  not  an  essential 
or  even  the  common  cause.  In  many  countries  where 
large  doses  of  quinine  are  given,  after  and  during  fever, 
no  such  effects  take  place.  In  analysing  the  cases  in 
an  endemic  area  there  is  no  close  relation,  either  as 
regards  dose  of  quinine  or  interval  between  taking 
quinine  and  the  onset  of  haemoglobinuria,  as  might  have 
been  anticipated  if  the  quinine  acted  as  the  determining 
cause.  In  a  few  instances  quinine  has  not  been  taken. 
In  many  the  dose  taken  is  no  larger  than,  or  not  as  large 
as,  that  the  person  was  in  the  habit  of  taking,  and  after 
the  onset  of  h?emoglobinuria  further  administration  even 
of  large  doses  of  quinine  does  not  usually  cause  fresh 
haemolysis.  Exposure  to  cold  and  wet  seems  to  often 
act  as  the  determining  cause,  but  a  few  of  the  cases  occur 
amongst  persons  who  have  no  chance  of  such  exposure. 

Various  hypotheses  have  been  formulated  in  the 
attempt  to  explain  why  a  disease  which  appears  to  be 
closely  connected  with  malaria  is  not  directly  due  to  the 
malarial  parasite.  A  want  of  balance  between  the  pro- 
duction of  h^emolysins  and  antihaemolysins  dependent 
partly  on  the  parasites  and  partly  on  blood  changes 
in  the  host  as  a  result  of  the  formation  of  antibodies 
appears  to  be  the  inost  promising. 

Seqiiclcv. — In  the  majority  of  cases  recoverv  is  com- 
plete, and  there  are  no  persistent  ill-effects  bevond  a 
liability  to  subsequent  attacks.  Sometimes  a  malarial 
attack  will  occur,  but  as  a  rule  there  is  freedom  from 
such  attacks.  In  rare  cases  there  mav  be  persistent 
albuminuria.  Parotiditis  has  been  known  to  occur,  and 
retinal  haemorrhages  or   haemorrhages  into  the  vitreous 


104  TROPICAL   MEDICINE   AND    HYGIENE 

may  lead  to  impaired  vision,  but  in  such  cases  complete 
recovery  of  sight  is  usual. 

Plroplasma. — Piroplasmata  have  been  frequently  looked 
for  but  never  found,  as  has  been  already  mentioned. 
There  is  no  relation  known  between  the  distribution 
of  any  species  of  tick  and  blackvvater  fever,  but  more 
work  in  this  direction  is  required.  The  distribution 
of  Ornithodoriis  monhata  does  not  correspond  with  that 
of  blackwater  fever. 

Prophylaxis. — The  close  relationship  in  Africa  between 
the  distribution  of  blackwater  fever  and  of  great  liability 
to  malarial  affection  points  to  the  desirability  of  dealing 
with  the  malaria. 

Persons  in  whom  quinine  produces  haemoglobinuria 
are  unsuited  for  residence  in  a  malarial  country.  In 
such  persons  it  is  sometimes  possible  to  treat  the  malaria 
with  quinine,  if  small  doses  of  quinine  very  gradually 
increased  are  employed.  Persons  who  have  never  had 
blackwater  fever  in  Africa  are  still  liable  to  an  attack  for 
some  months  after  their  arrival  in  England.  It  is  therefore 
advisable  that  the  prophylactic  use  of  quinine  should  be 
continued,  not  only  on  the  voyage  home,  but  for  two 
or  three  months  after  arrival  in  England.  Such  persons 
must  also  avoid  exposure  to  chill,  over-fatigue,  or  any 
depressing  influences. 

A  previous  attack  of  blackwater  fever  appears  to  pre- 
dispose to  other  attacks.  A  single  severe  attack  or  two 
milder  attacks  should  be  considered  as  disqualifying  that 
person  for  residence  in  an  endemic  area. 


I05 


CHAPTER   VIII. 

PIROPLASMOSIS. 

Piropliisniosis. — "  Malaria  "  of  cattle,  horses,  clogs,  &c. 
Piroplasmosis  is  the  term  sometimes  applied  to  the  affec- 
tion caused  by  certain  sporozoal  blood  paiasites  which, 
being  commonly  pear-shaped,  are  called  piroplasmata. 
The  piroplasmata  differ  from  the  haemamoebce  in  that, 
(i)  they  do  not  form  pigment ;  (2)  division  is  usually 
into  two,  sometimes  into  four,  and  the  young  forms  are 
not  immediately  set  free,  but  continue  to  grow  in  the  red 
corpuscle  in  which  they  live.  Ultimately  they  escape 
from  these  red  corpuscles.  It  is  probable  that  a  large 
proportion  of  their  nutriment  is  derived  by  osmosis  from 
the  blood  plasma  and  less  from  the  haemoglobin  than  in 
the  haemamoebje.  The  free  parasites  may  be  found  in 
the  plasma,  actively  motile  before  they  enter  other  cor- 
puscles ;  (3)  they  are  conveyed  in  all  known  instances  by 
ticks  of  various  genera.  The  diseases  are  transmitted  not 
by  the  tick  that  feeds  on  the  infected  animal,  but  by  the 
second  and  sometimes  the  third  generation  of  these  ticks, 
as  the  parasites  are  transmitted  to  the  eggs  and  develop 
in  the  young  ticks. 

The  piroplasmata  in  the  early  stage  have  no  definite 
vesicular  nucleus,  though  a  clear  non-staining  space 
or  vacuole  is  present.  The  chromatin  is  frequently  in 
two  equal  or  unequal  masses,  and  though  it  divides  to 
some  extent  the  complete  fragmentation  and  diffusion 
observed  in  the  malaria  parasite  does  not  occur. 

Division  is  more  by  a  process  of  budding  than  of 
breaking  up  into  spores.  The  pear-shaped  body  after 
escaping  from  a  red  corpuscle  enters  another  and  then 
becomes  a  rounded  amoeboid  mass.  In  this  stage  it  does 
not  escape  from  the  red  corpuscle.      After  a  time    two 


iG6  TROPICAL   MEDICINE   AND   HYGIENE 

processes  or  buds  are  formed  at  the  periphery  of  this 
rounded  body,  and  these  gradually  increase  in  size,  the 
chromatin  divides,  and  half  enters  each  of  these  buds. 
The  increase  in  size  in  the  buds  is  by  absorption  of  the 
original  protoplasmic  mass,  which  is  reduced  to  a  mere 
thread  connecting  the  two  bodies,  and  this  finally  is 
absorbed  and  the  two  pear-shaped  bodies  lie  free  in  the 
red  corpuscle.  They  may  remain  in  the  red  corpuscle 
for  some  time,  and  when  they  escape  enter  in  turn  red 
corpuscles,  before  they  again  become  amoeboid  and 
divide  and  so  repeat  the  cycle. 

Piroplasmata  occur  in  most  of  the  domesticated  animals 
and  cause  serious  disease,  and  frequently  death,  in  cattle, 
sheep,  horses  and  dogs.  They  have  been  described  in 
man,  but  their  occurrence  is  very  doubtful. 

By  some  observers  Leishman-Donovan  bodies,  now 
known  to  be  a  resting  stage  of  a  flagellate,  were  con- 
sidered as  piroplasmata.  In  all  the  diseases  of  domes- 
ticated animals  pyrexia  occurs,  not  showing  definite 
periodicity.  A  common  character  is  haemoglobinuria,  so 
much  so  that  the  popular  name  of  the  disease  in  cattle  is 
"  red-water  fever,"  in  sheep  ''  heart  fever."  In  dogs  the 
disease  they  cause  is  called  epidemic  jaundice,  on  account 
of  the  haemotogenous  colouring  of  the  conjunctiva  from 
the  haemolysis.  Although  haemolysis  is  a  common  result 
of  piroplasma  infection,  haemoglobinuria  is  by  no  means 
always  a  prominent  symptom.  Red-water  does  not 
occur,  for  example,  in  Rhodesian  or  East  Coast  cattle 
fever,  and  although  piroplasmosis  is  common  in  cattle 
throughout  the  East,  yet  haemoglobinuria  is  rarely  met 
with  except  in  animals  suffering  from  serious  intercurrent 
disease,  such  as  rinderpest,  or  among  those  imported 
from  countries  where  piroplasmata  do  not  occur. 

An  infection  with  piroplasma  in  cattle  appears  to  last 

during  the    whole   life   of   the   animal,    but   the   clinical 

"evidence  of  the  presence  of  the  parasites  disappears,  and 

though    the    animals    harbour    the    parasites    in    small 

numbers  they  seem  to  have  acquired  a  degree  of  toler- 


PIHOPLASMOSIS  107 

ance  that  enables  them  to  prevent  the  miUtiphcatifMi  of 
the  parasites  and  to  resist  the  effects  of  their  presence. 
Such  animals,  liowever,  though  in  s^ood  health  themselves, 
are  able  to  infect  ticks.  The  non-recognition  of  the 
practically  universal  infection  of  native  cattle  has  in 
several  instances  led  directly  to  the  destruction  of  im- 
ported animals,  as  in  the  process  of  immunizing  against 
rinderpest  virulent  blood  has  been  injected  into  newly 
imported  animals,  which  have  then  died  from  "red-water." 

Human  Piroplasniosis.  —  Several  observers  have  de- 
scribed piroplasmata  in  human  blood ;  so  far,  however, 
without  confirmation. 

A  very  fatal  form  of  fever,  occurring  in  the  Rocky 
Mountains  and  called  locally  spotted  fever,  was  attributed 
to  the  presence  of  a  piroplasma  in  the  blood,  and  infec- 
tion was  thought  to  be  due  to  a  tick  {perinoccntor  reticu- 
laris). Subsec|uent  observers  have  failed  to  find  the 
piroplasma,  but  confirm  the  opinion  that  it  is  a  disease 
carried  by  ticks  which  can  be  communicated  to  lower 
animals.  The  disease  occurs  chiefly  in  the  spring  and 
affects  white  races  only ;  it  is  more  common  in  persons 
under  than  over  forty,  and  in  males  than  females. 

The  incubation  is  short,  symptoms  commencing  two  to 
five  days  after  the  bite  of  a  tick.  The  onset  is  gradual 
and  the  general  symptoms  resemble  those  of  typhus 
fever,  but  are  more  severe,  and  a  rash  appears  on  the 
second  to  the  fifth  day.  The  rash  appears  first  on  the 
ankles  or  back,  but  soon  becomes  general.  It  is  at  first 
vesicular,  but  later  petechial,  jaundice  is  usual  and  des- 
quamation occurs  in  patients  who  survive. 

The  mortality  is  very  high,  between  70  and  80  per 
cent,  of  the  patients  dying,  usually  between  the  sixth  and 
eleventh  da^^s.  In  patients  who  survive  recovery  is 
gradual,  and  commences  about  the  end  of  the  second 
week.  Quuiine  is  said  to  be  the  only  drug  which  does 
good,  and  the  avoidance  of  tick-bites  is  suggested  as  a 
preventive. 

Post-iiioiicm  examination  shows  a  considerable  enlarge- 


I08      ,  TROPICAL   MEDICINE   AND   HYGIENE 

ment  of  the  spleen  and  acute  parenchymatous  degenera- 
tion of  other  intestinal  organs.  There  is  no  ulceration  of 
the  intestine.  By  many  the  disease  is  believed  to  be 
typhus. 

The  term  "  human  piroplasmosis  "  has  sometimes  been 
applied  in  India  to  cases  of  kala-azar,  but  it  will  be  seen 
that  this  disease  is  due  to  a  parasite  of  a  different  nature. 

Piroplasmata  have  also  been  described  in  the  blood  of 
a  cowherd  suffering  from  fever  during  the  presence  of 
Texas  fever  amongst  cattle  in  India.  This  observation 
also  lacks  confirmation. 

Bodies  resembling  piroplasmata,  but  easily  distinguish- 
able upon  careful  examination,  have  been  described  by 
Cropper  working  in  Palestine,  and  by  Smith  working  in 
America,  as  occurring  in  the  blood  of  persons  suffering 
from  severe  forms  of  malaria.  The  bodies  have  a  rota- 
tory but  no  amoeboid  movement ;  their  nature  is  unknown. 
They  do  not  stain  with  basic  stains.  The  edges,  probably 
the  edges  of  the  haemoglobin,  are  sometimes  stained 
irregularly.  Similar  bodies  have  been  found  by  Nuttall  in 
the  blood  of  dogs.     They  are  probably  not  parasites. 


J  09 


CHAPTER    IX. 


YELLOW  FEVER. 


The  parasitology  of  this  disease  is  unknown.  It  is 
in  no  way  connected  with  malaria,  but  as  it  has  been 
proved  to  be  carried' by  a  mosquito,  Stegoniyia  fasciata 
(S.  calopns),  and  as  there  is  further  proof  that  time  has 
to  elapse  after  the  infection  of  the  mosquito  before  it 
in  turn  becomes  infective,  development  must  take  place 
in  the  mosquito.  On  these  grounds  the  disease  is  here 
included  with  the  probably  protozoal  diseases. 

Yellow  Fever  is  characterized  by  fever,  intense  headache, 
jaundice,  and  albuminuria  increasing  steadily  in  amount ; 
by  tendency  to  haemorrhages  from  mucous  and  some- 
times from  cutaneous  surfaces,  and  by  haematemesis — 
"black  vomit."  In  fatal  cases  there  is  frequently 
suppression  of  the  urine. 

It  is  conveyed  from  man  to  man  by  mosquitoes 
belonging  to  the  genus  Stegouiyia. 

Geographical  Distribution. — It  is  essentiallv  a  disease 
of  the  New  World,  and  occurs  endemically  or  as 
epidemics  in  the  West  Indies  and  along  the  Atlantic 
coast  from  New  York  down  to  Rio  de  Janeiro.  It 
has  been  described  on  the  West  Coast  of  Africa,  and  has 
occurred  in  South  Europe,  on  the  Atlantic  coast  as  an 
imported  disease,  and  on  board  ship.  It  has  spread  to 
a  small  extent  even  in  English  ports  in  the  vicinitv  of 
infected  ships,  during  summer  months. 

It  is  usually  limited  to  the  larger  settlements  on  the 
coast  in  the  Tropics.  Ship  epidemics  were  common  in 
the  past,  but  are  now  rare. 


■no  TROPICAL   MEDICINE   AND   HYGIENE 

Clinical  Course. — The  onset  of  the  disease  is  sudden, 
but  not  invariably  with  a  rigor.  The  temperature  rises 
rapidly,  there  is  violent  headache,  most  intense  over  the 
frontal  region.  The  eyes  are  much  injected  and  often 
described  as  ferrety.  Jaundice  soon  appears  ;  the  con- 
junctiva and  skin  are  at  first  lemon-coloured,  but  soon 
deepen  to  a  bright  yellow  colour.  Vomiting  is  a  promi- 
nent symptom  ;  at  first,  merely  of  food,  then  watery, 
then  "  acid  vomit,"  and  later  almost  black — "  black 
vomit." 

The  act  of  emesis  is  performed  with  little  or  no  effort, 
and  the  amount  ejected  is  surprising.  The  vomit  seems 
rather  to  gush  out  than  to  be  forcibly  expressed.  There 
is  a  feeling  of  marked  and  decided  relief  after  each 
evacuation  of  the  stomach. 

Epigastric  pain  and  tenderness  occur  early  and  are 
intensified  by  pressure.  There  is  usually  an  intensely 
acid  or  bitter  taste  in  the  mouth. 

The  course  of  the  disease  is  best  considered  divided  into 
three  stages  as  described  by  Blair,  During  the  first  stage 
the  temperature  is  high  and  the  pulse  quick  and  bound- 
ing. The  headache  and  epigastric  pains  are  severe,  and 
the  vomit  is  free  from  blood  till  towards  the  close  of  the 
period.  The  urine  contains  albumin,  and  the  jaundice 
appears  and  progressively  deepens.  The  duration  of  this 
stage  is  from  three  to  four  days. 

The  passage  into  the  second  stage  is  rapid,  though  not 
exactly  by  crisis.  The  temperature  falls  to  normal  or 
subnormal,  the  pulse-rate  is  reduced,  the  restlessness, 
pain,  and  delirium  disappear,  and  the  patient  feels  much 
relieved,  and  often  quite  well.  The  general  appearance 
of  well-being  in  the  second  stage  is  deceptive  and  death 
may  occur,  in  such  a  patient,  and  he,  even  while  he  is 
sinking,  may  feel  quite  well. 

In  some  cases — the  mild  ones — this  remission  is  the 
end  of  the  disease  and  the  patient  steadily  continues  to 
improve,  and  passes  into  the  stage  of  convalescence  with- 
out secondary  fever. 


YELIXnV    VKVKU 


III 


In  other  cases,  after  a  short  apyrexial  peri(jd  or 
period  with  a  moderate  temperature,  the  tempera- 
ture again  rises — secondary  fever — the  vomiting  recurs, 
and  the  vomit  if  not  previously  mixed  with  blood  is  so  now. 
The  urine  becomes  more  and  more  loaded  with  albumin, 
and  diminished  in  amount,  and  the  distressing  symptoms 
again  recur.  This  is  the  most  dangerous  stage  and  may 
last  for  about  a  week  or  more.  In  cases  progressing 
favourably  the  symptoms  gradually  subside,  the  tempera- 
ture gradually  falls  and  the  amount  of  urine  increases 
whikst  the  albumin  decreases  and  convalescence  is  estab- 
lished. 

The    diagnosis    of    an    epidemic    of    yellow    fever    is 


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Fig.  32. — Yellow  Fever.     Severe  attack. 


not  difficult.  The  fever,  severe  headache,  increasing 
albuminuria  and  jaundice,  with  the  occurrence  in  a  pro- 
portion of  the  cases  of  "  black  vomit,"  render  the 
diagnosis  certain. 

The  limitation  of  the  disease  to  certain  quarters,  or 
even  streets  of  a  town,  and  the  dependence  of  one  case 
on  preceding  cases  are  all  aids  in  this  diagnosis.  The 
diagnosis  of  isolated  cases  is  more  difficult.  Acute 
yellow  atrophy  of  the  liver  may  closely  simulate  the 
severe  forms  of  the  disease,  malaria  with  jaundice, 
and  Weil's  disease  have  each  manv  points  of  resemblance. 

There  are  certain  points  of  resemblance  between  yellow 


112  TROPICAL   MEDICINE   AND   HYGIENE 

fever  and  blackwater  fever  that  have  in  the  past  led  to 
a  confusion  between  the  two  diseases^  so  much  so  that 
both  have  been  considered  to  be  manifestations  of 
malaria,  and  are  still  often  mistaken  for  "  bilious  remittent 
fever  "  with  jaundice. 

The  points  of  similarity  are  the  jaundice,  liability  to 
suppression  of  urine,  and  vomiting;  the  temperature 
charts  are  not  unlike  in  the  two  diseases,  as  in  both  there 
is  a  remission  in  the  pyrexia  between  the  primary  and 
secondary  fever.  Clinically  there  are  important  differ- 
ences. Haematemesis  is  very  rare  in  blackwater  fever, 
and  common  in  yellow  fever.  Haemoglobinuria  or 
metlijemoglobinuria  is  invariable  in  blackwater  fever  and 
very  rare  in  yellow  fever,  though  there  may  be  haema- 
turia.  In  neither  disease  are  malarial  parasites  found  in 
the  blood,  during  the  attack,  and  in  yellow  fever  the 
increase  in  the  relative  number  of  the  large  mononuclear 
leucocytes  is  not  found.  The  intense  headache  in  the 
early  stages  of  yellow  fever  is  not  present  in  blackwater 
fever,  and  the  repeated  rigors  so  common  in  blackwater 
fever  are  usually  absent  in  yellow  fever. 

Treatment. — A  preliminary  purge  seems  to  be  of  great 
importance,  and  calomel  is  frequently  used  for  this 
purpose.  Many  drugs  have  been  employed,  and  a  treat- 
ment for  which  great  success  was  claimed  was  by  large 
doses  of  calomel  and  quinine,  20  grains  of  each  being 
given.  All  later  work  shows  that  quinine  has  no  effect 
on  the  disease. 

Carbolic  acid,  in  drop  doses  every  hour,  and  other 
intestinal  antiseptics  have  also  enjoyed  a  great  reputation. 
There  does  not  appear  to  be  any  drug  with  a  specific 
action.  The  present  treatment  is  that  introduced  by 
Sternberg,  well  diluted  bichloride  of  mercury  and  car- 
bonate of  soda  being  given  frequently  in  small  doses. 

Nursing. — Careful  nursing  is  of  great  importance.  The 
room  must  be  kept  very  quiet  and  dark,  as  there  is  great 
intolerance  of  light.  Vomiting  must  be  checked  if  pos- 
sible, and  opium    is    contraindicated.     All  food,  drinks, 


YELLOW   FEVER  II3 

and  medicines  must  be  given  in  small  quantities  at  a 
time. 

Ice-bags  or  cold  compresses  to  the  abdomen  give  more 
relief  in  most  cases  than  hot  applications. 

Protection  from  the  bites  of  mosquitoes  must  be  very 
carefully  attended  to  in  order  to  prevent  the  spread  of  the 
disease  and  the  infection  of  the  attendant,  especially  dur- 
ing the  iirst  stage  of  the  disease.  The  danger  is  greatest 
at  night,  as  one  of  these  mosquitoes  which  has  once  fed 
becomes  a  feeder  at  night  mainly.  The  bed  must  be 
always  screened  off  in  a  mosquito  net  sufficiently  large 
for  the  attendant  also  to  be  inside  it,  and  any  mosquitoes 
that  obtain  entrance  to  the  net  must  be  caught  and  killed, 
as  otherwise  they  may  become  infective  in  ten  days.  The 
netting  must  not  be  too  coarse,  as  the  S.  fasciata  can 
pass  through  a  mesh  of  15  to  the  square  inch.  All  the 
evidence  is  opposed  to  the  belief  that  any  discharges  from 
the  patient  are  infective. 

Mosquito  larvae  in  the  room  should  be  destroyed, 
and  no  breeding-places — flower- vases,  water-jugs,  &c. — 
allowed  to  remain  in  the  room. 

Pathology  and  Morbid  Anatomy. — The  organism  that 
causes  yellow  fever  has  not  been  isolated.  It  is  present 
in  the  blood  of  the  patient  during  the  first  three  days  of 
the  disease,  and  is  so  minute  that  blood  serum  of  such 
a  patient  retains  its  infectivity  after  passage  through  a 
Berkefeld  filter.  This  serum  if  injected  into  a  non- 
immune subject  will  cause  an  attack  of  the  disease,  not 
merely  a  toxemia,  as  the  blood  of  this  person  is  infective, 
showing  that  he  also  harbours  the  parasite.  The  morbid 
changes  due  to  the  action  of  this  unknown  organism 
result  in  liability  to  haemorrhages,  congestion  of  viscera, 
and  extreme  fatty  degeneration  of  the  cells  in  the  liver, 
kidneys,  and  elsewhere.  This  fatty  degeneration  is  so 
marked  that  the  liver  and  kidneys  are  pale  yellow  in  colour 
and  extremely  friable.  There  will  be  no  malarial  pigment 
unless  there  have  been  previous  attacks  of  malaria.  The 
stomach  is  always  congested,    submucous  haemorrhages 


114  TROPICAL   MEDICINE   AND    HYGIENE 

are  common,  and  the  contents  of  the  stomach  and  ah- 
mentary  canal  are  black  and  tarry,  even  when  there  has 
been  no  black  vomit.  Subserous  haemorrhages  are  always 
present  and  the  serous  membranes  are  stained  with  bile. 

All  attempts  at  isolating  an  organism  that  can  be 
regarded  as  the  cause  of  the  disease  have  failed.  From 
time  to  time  organisms  have  been  described,  and  the 
one  that  for  some  years  attracted  considerable  attention 
was  a  bacillus  described  by  Sanarelli.  This  organism, 
one  of  the  coli  group,  has  been  showai  to  be  that  of 
hog-cholera. 

Though  the  cause  has  not  been  discovered,  it  is  now 
known,  as  the  result  of  the  experimental  work  of  Reed 
and  Caroll,  fully  confirmed  by  numerous  observers,  that 
the  infective  agent  is  imbibed  with  the  blood  of  patients 
by  certain  mosquitoes,  and  that  such  mosquitoes  after 
a  definite  period  of  ten  to  twelve  days  are  in  turn  capable 
of  infecting  non-immunes.  These  experiments  have 
shown  : — 

(i)  That  neither  in  the  vomit,  black  or  otherwise,  in  the 
faeces,  or  sweat,  or  other  discharges  from  the  patients  is 
any  infective  agent  contained,  but  that  it  is  contained  in 
the  blood  during  the  first  three  days  of  the  attack. 

(2)  That  mosquitoes  {S.  fasciata)  can  convey  the  disease, 
and  that  the  other  common  and  domestic  mosquitoes  do 
not  so  carry  the  disease. 

The  conditions  necessary  for  the  conveyance  of  the 
disease  by  these  mosquitoes  are  : — 

{a)  That  the  mosquito  must  have  fed  on  the  blood 
of  a  yellow  fever  patient  during  the  early  stage,  first, 
second  or  third  day  of  the  disease. 

(6)  That  the  mosquito  must  have  lived  for  ten  days 
after  this  feeding. 

(c)  That  the  person  bitten  in  the  second  instance  must 
be  susceptible. 

This  series  of  events  shows  that  the  parasite  of  yellow 
fever  requires  development  in  the  mosquito  before  it 
can  be  injected  into  man,  and  that  it  is  not  simply  a 
transference  of  the  organisms  from  one  man  to  another. 


YELLOW   FEVER  II5 

M.'irclioux  and  Simond  claim  that  the  mosquitoes  may 
transmit  the  organism  to  their  offspring,  though  the  more 
extensive  observations  of  Kosenau  and  Goldbergcr  have 
failed  to  confirm  these  results,  and  the  method  in  which 
yellow  fever  is  spread  is  in  more  accoidance  with  tlie 
transmission  by  the  adults  than  in  this  manner. 

The  period  of  incubation  of  yellow  fever  after  the  bite 
of  an  infective  mosquito  varies  little  and  is  usually  from 
three  to  four  davs,  very  rarely  over  five.  In  persons 
partially  immune  a  longer  period  of  incubation  may  be 
met  with.  The  early  cases  in  an  epidemic  are  twelve  to 
fifteen  days  after  a  case  is  introduced,  as  the  mosquitoes 
have  to  be  infected  and  become  infective,  which  takes 
ten  days,  and  then  the  person  infected  by  them  will  not 
develop  the  disease  for  two,  three  or  four  days.  The 
incubation  period  for  an  epidemic  is  therefore  about  two 
weeks.  Most  of  the  etiological  factors  connected  with 
yellow  fever  are  closely  related  to  the  conditions  favour- 
able for  the  life  and  multiplication  of  S.  fasciata,  but  this 
insect  is  more  widely  spread  than  yellow  fever,  and  is 
only  of  importance  in  this  connection  when  persons  with 
yellow  fever  are  present  or  are  imported. 

Prophylaxis.  —  The  carrier  of  yellow  fever  is  known, 
and  for  eflfective  prophylaxis  thorough  knowledge  of 
the  habits  of  this  insect  is  required,  and  the  means  of 
identification.  It  is  possible  that  other  members  of  the 
same  group  may  carry  yellow  fever. 

The  subfamily  of  the  Culicidce  to  which  the  St  ego  my  la 
belongs  is  the  Citllcina,  characterized  by  a  straight  or 
nearly  straight  proboscis  adapted  for  piercing,  by  a  nude 
metanotum,  by  a  trilobed  scutellum,  and  by  having  the 
palpi  short  in  the  female  and  long  in  the  male.  The 
scales  on  the  wings,  thorax,  head  and  scutellum  vary  in 
the  different  members  of  this  subfamilv,  and  these  varia- 
tions  are  made  the  basis  of  the  subdivision  of  the  Cullclna 
into  a  large  number  of  genera. 

The  genus  Stegomyla  diit'ers  from  the  other  Culicinas  in 
that  there  are  no  narrow  curved  scales  on  the  head  or 


ri6  TROPICAL   MEDICINE   AND    HYGIENE 

scutellum.  They  are  small  mosquitoes  and  usually  black 
with  brilliant  silver-white  markings.  These  markings, 
especially  those  on  the  thorax,  serve  to  distinguish  the 
different  species,  and  in  S.fasciata  there  is  a  faint  central, 
narrow  silver  line  on  the  dorsum,  and  on  each  side  of 
this  a  more  conspicuous  curved  line. 

The  S.  fasciata  (S.  calopiis)  is  commonly  known  as  the 
"  tiger  mosquito,"  because  of  the  brilliant  striping  of  the 
legs  and  abdomen. 

The  breeding-places  and  habits  of  the  Stegomyia  in 
general,  and  of  S.  fasciata  in  particular,  differ  greatly 
from  those  of  the  Culicidae  already  considered,  and  the 
prophylactic  measures  must  be  varied  accordingly. 
Stegomyia  eggs  are  laid  singly,  and  have  no  lateral  air- 
floats.  They  are  covered  with  a  thick  shell.  They  float 
for  a  time  on  the  surface  of  the  water,  but  ultimately  sink 
and  lie  at  the  bottom  of  the  water  in  which  they  were 
deposited.  These  eggs  are  not  killed  by  immersion  in 
water,  nor  are  they  destroyed  by  prolonged  desiccation. 

This  extraordinary  vitality  of  the  eggs  is  the  cause  of 
the  great  variety  of  breeding-places,  and  of  the  wide 
dissemination  of  this  mosquito. 

In  the  first  place  eggs  are  often  deposited  in  quite  small 
receptacles,  shallow  pools,  gutters  of  houses,  old  tins  used 
for  preserved  foods,  broken  bottles,  empty  cocoanut  shells, 
&c.,  and  it  is  immaterial  if  this  deposition  takes  place  at 
the  end  of  a  spell  of  wet  weather,  as  the  eggs  will  remain 
alive  even  if  the  water  dries  completely.  With  the  next 
rain,  either  there  will  be  sufficient  rain  to  moisten  the 
eggs,  or  there  will  be  an  excessive  amount,  so  that  these 
receptacles  overflow.  In  the  first  case  the  eggs  will  hatch 
where  they  were  laid  ;  in  the  second,  they  will  be  washed 
away  into  some  larger  and  perhaps  more  permanent  col- 
lection of  water. 

Eggs  that  have  fallen  to  the  bottom  of  a  pond  remain 
alive,  and  if  in  taking  water,  as  on  board  a  ship,  the 
bottom  is  at  all  disturbed,  the  eggs  will  be  taken  with  the 
water,  and  hatch  out   and   develop  in  the  water-barrels. 


YELLOW    KKVER 


117 


Old  wooden  barrels  in  which  water  has  been  kept,  if  not 
well  cleansed,  will  often  be  found  full  of  larv;e  within 
twenty-four  hours  if  refilled  with  water.  Such  bai-)-eIs  are 
often  used  for  storage  of  watei"  on  a  small  scale  and  for 
catching  roof  water,  and  whether  kept  indoors  or  out  (jf 
doors  are  most  prolilic  breeding-places.  With  the  onset 
of  the  wet  season  these  species  of  mosquitoes  very  rapidly 
become  abundant.  The  mature  eggs  are  present  in  old 
beds  of  dried  puddles,  and  in  every  receptacle  that  will 
hold  even  a  few  drops  of  water,  and  these  hatch  out  with 
the  first  rain,  and  if  rain  continues  the  pupae  will  form  in 
a  week,  and  a  day  or  two  later  the  imagines  emerge. 
Light  is  not  necessary  for  the  development  of  these  larvae, 
so  that  cisterns  and  tanks  are  suitable  breeding  grounds. 
The  larvae  have  a  respiratory  syphon  or  tube  attached 
to  the  eighth  abdominal  segment.  This  syphon  is 
present  in  all  the  Culicinae,  but  varies  greatly  in  length. 
In  the  Stegomyia  it  is  a  short,  broad,  stumpy  syphon, 
shorter  than  in  most  of  the  commoner  Culiciiuv.  The 
mouth-parts  are  simple,  the  clumps  of  hairs — the  brushes 
— situated  on  each  side  of  the  mouth  are  short,  stiff,  and 
not  very  abundant.  The  mandibles  and  maxillje  are 
powerful.  These  larvae  feed  at  the  bottoms  or  sides  of 
the  water  in  which  they  live,  and  mainly  on  lower  forms 
of  animal  and  vegetable  life.  They  require  abundant 
food  and  serve  to  keep  down  algae.  They  can  remain 
under  water  for  a  long  time,  and  often  escape  notice  in 
that  way.  When  breathing  or  resting  they  hang  with 
their  heads  down  from  the  surface  of  the  water,  and  in 
butts  and  barrels  are  often  numerous  enough  to  blacken 
the  surface  of  the  water.  Any  slight  disturbance  appears 
to  alarm  them,  as  the  whole  lot  will  then  immediately 
dive  to  the  bottom  of  the  barrel,  and  may  remain  there 
for  some  time,  and  the  surface  of  the  w^ater  be  free  from 
larvae.  The  larvae  are  very  hardy,  active  in  their  move- 
ments, and  less  readily  killed  by  desiccation  than  most 
larv^.  The  larvae  live  well  on  board  ship.  They  require 
a   fairly  high    temperature,  and  are   killed  when  frozen. 


Il8  TROPICAL   MEDICINE   AND   HYGIENE 

They   do    not   occur   outside   tropical    and    sub-tropical 
regions. 

The  adults — imagines — are  hardy  mosquitoes,  and  most 
species  feed  readily  on  man.  Some  jungle  species  bite 
by  day  only,  many  feed  both  at  night  and  by  day,  but 
S.  fasciata  at  first  will  feed  by  day  or  night,  but  after  once 
feeding  continue  to  feed  at  night  only.  Many  species  are 
jungle  mosquitoes,  but  some  of  these,  as  S.  scntellaris, 
much  more  numerous  in  settlements  in  the  vicinity  become 
of  jungle,  and  readily  become  domesticated.  S.  fasciata 
is  far  more  abundant  on  the  sea-coast,  and  in  many 
countries,  such  as  the  Guianas  and  the  Malay  Peninsula, 
is  rarely  met  with  except  in  coast  settlements  and  towns. 
Though  strong,  active  mosquitoes,  they  do  not  take 
extensive  flights,  or  go  far  .from  their  breeding-places. 
It  follows  that  when  these  mosquitoes  are  numerous, 
the  breeding-places  are  close  at  hand.  As  a  rule,  the 
breeding-places  of  the  mosquitoes  are  in  the  immediate 
surroundings  of  a  house,  and  destruction  of  these  breed- 
ing-places will  result  in  the  freedom  of  that  house  from 
these  mosquitoes. 

The  places  to  look  for  breeding-places  of  S.  fasciata 
are  : — 

(i)  The  back  of  servants'  quarters,  as  behind  these 
empty  tins,  bottles,  and  broken  crockery  of  all  kinds  are 
allowed  to  accumulate.  If  there  is  long  grass  these 
receptacles  are  hidden  by  it,  and  thus  sheltered  from  the 
sun,  retain  water  for  a  long  time. 

(2)  Tanks,  barrels,  water-butts,  used  for  collecting 
or  storing  water.  The  largest  as  well  as  the  smallest 
are  common  breeding-places.  Wooden  receptacles  are 
perhaps  the  most  likely  to  harbour  the  larvae.  The 
warning  that  any  incautious  movement  is  to  be  avoided 
in  examining  such  places  must  be  remembered,  as  the 
larv^,  if  they  are  not  on  the  surface,  cannot  be  seen. 
Badly  graded  gutters  are  also  fertile  breeding-places. 
The  ordinary  roof-gutter  is  apt  to  sag,  and  even  if 
properly  graded    is  liable   to   be  blocked  by  leaves  and 


YELLOW   FEVER  II9 

other  debris,  so  that  pools,  permanent  in  the  wet  season, 
are  formed.  Moreover,  egjL^s  deposited  on  their  extensive 
surface  are  carried  down  into  the  water-tanks  and  there 
develop.  Some  authorities  condemn  roof-flutters  for 
these  reasons,  but  there  is  no  reason  why  roof-gutters 
should  not  be  properly  graded  and  kept  clean,  and  it  is 
of  little  importance  that  eggs  are  washed  down  if  the 
mosquitoes  that  develop  in  the  tank  cannot  escape 
from  it. 

(3)  In  houses,  bath-tubs,  vessels  for  holding  flowers, 
flower-pots,  even  filters,  such  as  the  drip  stone  filters, 
water-coolers,  and  every  receptacle  for  water  will  serve 
as  a  breeding-place.  These  are  frequently  found  in 
unoccupied  rooms.  As  these  mosquitoes  can  breed  in 
foul  water,  they  may  be  present  in  the  receptacles  for 
kitchen  refuse,  and  even  cesspits.  Stable  cesspits,  stable 
buckets  and  drains  are  often  the  breeding-places  of  these 
mosquitoes. 

In  preventing  the  spread  of  yellow  fever,  a  knowledge 
of  their  breeding-places  is  essential.  In  any  country  into 
which  yellow  fever  may  be  introduced  the  extermination 
of  these  mosquitoes  will  render  the  spread  of  the  disease 
impossible  ;  and  in  all  countries  their  extirpation  will 
greatly  increase  comfort.  In  a  scattered  settlement  it 
is  an  easy  and  inexpensive  matter  to  render  a  house 
free  from  this  species  of  mosquito,  but  constant  care  is 
required.  The  important  point  is  that  in  such  a  place 
the  breeding-places  are  in  the  immediate  surroundings 
of  the  house.  The  occupier  breeds  his  own  mosquitoes. 
In  a  more  crowded  settlement  continued  efforts  are  re- 
quired, and  it  should  be  made  compulsory  for  each 
occupier  to  free  his  own  property  from  breeding-places  ; 
or  the  whole  work  may  be  done  by  the  municipality  at 
the  common  expense.  A  combination  of  these  methods 
is  most  effective.  It  should  be  compulsory  on  the 
occupier  to  free  the  actual  premises  from  breedmg- 
places,  and  to  have  his  water-tanks  so  protected  that 
mosquitoes  cannot  escape    from  them,  and  to    see   tliat 


I20  TROPICAL   MEDICINE   AND    HYGIENE 

no  accumulation  of  empty  tins  and  bottles  is  present 
in  his  compound.  The  municipality  should  remove 
such  bottles,  and  inspect  and  report  on  the  condition 
of  drains,  gutters,  tanks,  and  stable  surroundings  as  to 
their  freedom  from  larvae,  and  should  make  recom- 
mendations to  the  occupier  and  enforce  the  carrying  out 
of  such  recommendations.  The  gutters  must  be  well 
graded  and  kept  clean.  The  pipes  supplying  water  to 
the  tanks  must  be  long  enough  to  reach  the  bottoms  of 
such  tanks,  otherwise  the  mosquitoes  as  they  hatch  out 
will  escape  through  this  pipe.  The  manhole  must  be 
kept  covered,  and  it  is  better  to  have  a  double  covering, 
an  inside  one  of  gauze,  and  the  ordinary  solid  one  over 
it.  It  is  useless  to  attempt  to  render  the  supply  pipe 
impervious  to  mosquitoes  by  placing  a  gauze  diaphragm 
in  any  part  of  it,  as  the  meshes  soon  become  clogged 
and  the  water  will  not  pass  through.  An  inspection  and 
collection  of  any  portable  breeding-places,  e.g.,  bottles, 
&c.,  should  be  made  twice  a  week,  and  any  foul  drains 
or  cesspits  should  be  treated  with  crude  petroleum,  or 
better,  some  such  poison  as  tuba  root  {Derris  elliptica.) 

With  a  good  organization,  with  the  active  support  of 
the  intelligent  section  of  the  community,  and  stringent 
regulations  well  enforced,  the  cost  of  extirpation  of  this 
mosquito  is  not  prohibitive. 

Roof  water  forms  the  best  available  supply  of  drinking 
water  in  many  places,  so  that  measures  that  prevent  its 
infection  cannot  be  overlooked. 

In  a  town  not  so  protected,  or  only  partially  protected 
so  that  some  mosquitoes  of  the  species  Stegomyia  fasciata 
are  present,  the  introduction  of  a  patient  with  yellow 
fever  is  a  source  of  danger  to  the  whole  community. 
This  danger  can,  by  energetic  measures,  be  reduced  to  a 
minimum, 

(i)  All  cases  of  fever  must  be  at  once  reported  and 
enquired  into.  Any  that  are  yellow  fever  must  be  at 
once  isolated.  In  a  port  where  yellow  fever  is  likely  to 
be  introduced,  the  machinery  for  the  registration,  identi- 


YELLOW   FEVEK  121 

fication,  and  isolation  of  cases  must  be  kept  in  working 
order,  and  form  a  department  or  bureau  that  is  at  all 
times  available. 

(2)  If  there  is  a  case  of  yellow  fever  the  patient  must 
be  removed  to  another  room  and  placed  inside  a  mos- 
quito net,  and  kept  there  night  and  day  till  convalescent. 

(3)  The  room  from  which  the  patient  has  been  re- 
moved must  be  at  once  closed,  and  all  places  where 
mosquitoes  can  escape  blocked.  The  room  must  then 
be  fumigated  with  burning  sulphur  i|  lb.,  or  pyrethrum 
2  lb.,  to  each  1,000  cubic  ft.  As  soon  as  possible  after  the 
fumigation  the  floor  must  be  swept,  and  the  sweepings 
at  once  burnt,  as  mosquitoes  may  revive  after  such  a 
fumigation.  The  attendants,  those  engaged  in  fumigation 
or  mosquito  destruction,  and  any  persons  having  business 
in  the  house,  must  be  protected  by  suitable  clothing  from 
mosquitoes. 

(5)  In  adjoining  houses  every  effort  should  be  made 
to  destroy  the  mosquitoes,  as  some  may  have  escaped 
to  them.  If  the  case  of  yellow  fever  is  detected  early, 
when  these  precautions  are  adopted  there  is  frequently 
no  spread  of  the  disease,  because  the  mosquitoes,  as  in 
malaria,  are  not  capable  of  infecting  human  beings  in 
less  than  ten  days  after  biting  the  patient. 

Where  the  first  case  is  not  detected  early,  and  the 
disease  has  spread,  each  case  as  it  is  reported  must  be 
treated  in  the  same  manner  as  an  original  case.  The 
success  of  the  measures  depends  on  each  case  being 
reported  early,  and  a  thoroughly  efficient  central  bureau 
is  therefore  essential. 

When  an  outbreak  does  occur  measures  for  the 
destruction  of  the  larv^  must  be  most  energetically 
pushed. 

For  the  success  that  has  attended  such  prophylactic 
measures  the  reader  is  referred  to  the  reports  as  to 
the  sanitation  of  Havana,  New  Orleans,  and  the  Panama 
Canal  Works. 

Importation    of    disease    is    usually   by    ship.      Either 


122     ,  TROPICAL   MEDICINE   AND   HYGIENE 

infected  mosquitoes  are  introduced  or  infected  persons. 
Infected  mosquitoes  may  be  brought  in  with  the  cargo 
or  in  private  baggage,  and  in  that  case  the  focus  of  the 
epidemic  is  the  place  where  the  baggage  is  opened. 

Ship  Epidemics.  —  S.  fasciata  can  thrive  on  board 
ship,  and  can  be  transported  for  long  distances  by  sea 
as  eggs,  larvae,  or  adults.  The  adult  mosquitoes  may 
be  infected  in  one  port  and  only  become  infective 
after  reaching  a  second  port,  and  then  may  give  rise  to 
an  epidemic  in  the  vicinity  of  the  wharves.  It  is  quite 
possible  in  a  voyage  of  a  week  or  less  that  the  crew  of 
the  ship  might  escape  infection,  and  the  source  of  infec- 
tion of  the  port  would  not  then  be  known.  It  is  different 
in  cases  where  the  mosquitoes  become  infective  whilst 
at  sea.  In  such  a  case  a  large  proportion  of  the  sus- 
ceptible crew  may  acquire  yellow  fever. 

The  mosquitoes  need  not  be  numerous,  but  every 
attempt  must  be  made  by  fumigation  of  one  part  of 
the  ship  after  the  other  to  destroy  any  mosquitoes,  and 
the  sweepings  as  on  land  must  be  burnt  at  once. 
S.  fasciata  become  torpid  with  cold,  and  consequently 
such  epidemics  subside  four  or  five  days  after  reach- 
ing colder  latitudes,  but  in  summer  may  continue  to 
develop  as  far  north  as  England,  and  may  spread  in 
the  vicinity  of  the  wharves  as  the  mosquitoes  escape 
from  the  ship.  In  some  cases  the  infection  has  remained 
in  the  ship  for  several  months,  even  when  it  has  not 
been  occupied  for  this  period.  In  a  sheltered  warm 
part  of  a  ship  these  mosquitoes  may  live  for  that  period. 


123 


CHAPTER  X. 

FLAGELLATA. 

The  Mastigophora  or  Flagcllata  form  a  group  of  organ- 
isms that  have  long  been  known  both  21s  free-living  as 
well  as  in  parasitic  forms.  The  main  characteristic  is  the 
modification  of  a  part  of  the  cell  to  form  an  apparatus 
for  locomotion  consisting  of  one  or  more  motile  flagella. 
The  essential  part  of  this  fiagellum  is  not  attached  to  nor 
does  it  arise  from  the  ectosarc,  but  it  is  derived  from  a 
portion  of  the  chromatin  mass  contained  in  the  endosarc. 

The  nucleus  is  not  vesicular  and  contains  abundant 
chromatin,  which  is  diffused  throughout  it.  A  second 
more  compact  but  smaller  chromatin  mass,  the  inicro- 
nucleus,  cenirosoine,  or  blepJiaroplast,  is  contained  in  the 
endosarc,  and  the  fiagellum,  which  also  contains  chro- 
matin, arises  in  relation  to  this  mass. 

In  the  presence  of  the  fiagellum,  the  absence  of  amoeboid 
movements,  in  the  character  of  the  nucleus,  as  well  as  in 
the  method  of  multiplication  by  longitudinal  fission,  the 
flagellates  would  appear  to  be  absolutely  distinct  from  the 
haemosporidia.  Recent  work,  however,  shows  that  the 
distinction  is  not  so  absolute  as  was  supposed. 

Flagellates  may  have  a  resting  form  in  which  they 
become  rounded  and  lose  their  flagella,  and  are  then  not 
unlike  some  of  the  lijemosporidia,  though  even  then  the 
two  unequal  chromatin  masses  serve  as  a  distinction. 
Schaudinn  considered  that  he  had  proved  that  certain  of 
the  trypanosomes  could  assume  a  gregarine  form  after 
losing  the  flagella  and  then  closely  resemble  the  product 
of  the  fertilization  of  the  macrogamete  of  a  hcemo- 
sporidium  by  a  microgamete.  His  work  on  the  subject 
illustrates  the  extreme  complexity  of  the  problem,  but  has 
not  been  confirmed  in  many  important  respects.  The 
most  important  part  of  his  work  was  with  the  halteridium. 


124  TROPICAL   MEDICINE   AND   HYGIENE 

Special  interest  attaches  to  the  halteridium,  a  parasite 
in  the  red  corpuscles  of  many  species  of  birds,  partly 
because  it  was  in  a  species  of  this  parasite  that  McCallum 
first  observed  the  fertilization  of  a  female  gamete  by  a 
male  gamete,  resulting  in  the  formation  of  an  ookinet  or 
travelling  vermicule,  and  partly  because  of  Schaudinn's 
work  on  a  species  occurring  in  the  little  owl,  Athene 
nodiia;.  The  halteridium  has  long  been  considered  as 
being  a  hsemamoeba,  closely  allied  to  the  malarial  para- 
sites of  man,  but  Schaudinn  believes  that  it  is  but  a  stage 
in  the  life-history  of  a  trypanosome  which  he  calls 
Trypanosoma  noctiice.  Schaudinn's  opinions  have  not 
received  universal  acceptance,  some  observers  saying  that 
the  owl  harbours  a  trypanosome  in  addition  to  halteri- 
dium, and  that  Schaudinn  confused  the  changes  occurring 
in  the  two  classes  of  parasites.  A  brief  epitome  of  them 
is  given  here,  as  there  are  many  points  in  which  further 
information  as  to  the  full  life-history  of  trypanosomes  is 
required. 

Schaudinn's  views  (condensed,  modified,  &c.)  are 
therefore  here  briefly  considered.  It  will  be  convenient 
to  start  with  the  ookinet  of  the  halteridium  resulting  from 
the  fertilization  of  the  female  gametocyte  by  the  male 
gamete,  and  to  trace  the  life-cycle  of  the  organism  back 
to  this  stage  again.  The  ookinet  is  formed  in  the  stomach 
of  the  gnat  in  which  union  of  the  sexual  forms  of  the 
halteridium  occurs  very  shortly  after  the  ingestion  of 
infected  blood.  It  corresponds  closely  with  the  similar 
stage  of  the  malarial  parasite  and  is  a  fusiform 
body,  containing  in  its  cytoplasm  the  nucleus  re- 
sulting from  the  fusion  of  the  male  and  female  elements, 
some  reserve  materials,  a  few  pigment  granules  and 
vacuoles. 

When  first  formed  all  ookinets  are  similar  in  appear- 
ance, but  they  soon  become  distinguishable  into  three 
forms,  indifferent  (hermaphrodite),  male  and  female, 
recognizable  by  variations  in  their  cytoplasm,  nucleus, 
reserve  material,  and  relative  size  and  shape. 


KLAOKLLATA 


125 


A  process  common  to  some  fcjrms  oi  0(jkincts,  though 
it  may  not  be  completed  until  after  differentiation  has 
occurred,  is  the  extrusion  of  pigment  and  residual 
material.  Before  the  different  forms  become  distinguish- 
able certain  ciianges  have  occurred,  chiefly  affecting  the 
nucleus.  The  nucleus,  as  has  been  seen,  consists  of  b(;th 
male  and  female  elements.  Each  of  these  is  subdivided 
into  a  trophic  portion  and  a  kinetic  portion,  concerned 
respectively  with  the  nutrition  and  movement  of  the 
organism. 

In  all  forms,  the  trophic  and  kinetic  portions  of  the 
nucleus  become  separated  eventually,  the  former  be- 
coming the  tropho-nucleus  and  the  latter  the  kineto- 
nucleus  of  a  trypanosome. 

In  the  indifferent  ookinet  the  nucleus  soon  becomes 
divided  into  two  portions,  the  larger  of  which  is  the 
tropho-nucleus,  and  undergoes  at  this  stage  little  further 
change.  The  smaller  part,  which  remains  connected  with 
the  larger  by  a  fine  thread,  the  remains  of  the  axial 
spindle,  passes  towards  the  outer  part  (ectoplasm)  of  the 
ookinet,  and  at  the  same  time  towards  the  pointed 
anterior  end,  where  it  again  divides,  and  part  of  it  ulti- 
mately forms  the  free  edge  of  the  undulating  membrane 
(the  membrane  itself  being  formed  by  the  flattening  of 
the  anterior  part  of  the  organism)  and  the  flagellum. 
The  other  part  remains  on  the  kineto-nucleus  of  the 
trypanosome,  and  makes  towards  the  posterior  part  of 
the  organism,  drawnng  with  it  the  central  end  of  the 
flagellar  apparatus.  In  this  way  a  trypanosome  is  formed 
with  its  small  kineto-nucleus  posterior  to  the  larger 
tropho-nucleus,  and  with  an  undulant  membrane  ex- 
tending nearly  the  whole  length  of  the  organism. 

When  thus  fully  developed,  the  indifferent  trypanosome 
multiplies  by  fission.  The  nuclei  first  divide,  then  the 
motor  apparatus  is  duplicated,  and  finally  the  cytoplasm 
divides  into  two  trypanosomes.  This  multiplication  by 
fission,  which  is  limited  to  indifferent  forms,  mav  occur 
several  times  and  may  give  rise,  in  the   later   multiplica- 


126  TROPICAL   MEDICINE   AND    HYGIENE 

tions   at   any   rate,    to    male   and   female   as   well   as   to 
indifferent  trypanosomes. 

After  a  certain  time  this  form  of  multiplication  ceases 
and  the  trypanosomes  become  attached  to  the  epi- 
thelial cells  of  the  gnat's  stomach,  and  these  assume  a 
resting  gregariniform  stage.  The  flagellum  may  be 
reduced  to  a  short  rod,  or  may  disappear  altogether, 
and  the  parasite  becomes  rounded  and  inactive.  Binary 
fission  may  now  occur,  and  large  masses  of  gregarini- 
form parasites  thus  result. 

From  this  gregariniform  stage  trypanosomes  are  again 
developed,  the  kineto-nucleus  giving  rise  to  a  flagellum 
and  the  cytoplasm  becoming  elongated.  The  male 
ookinets  are  much  smaller  than  the  indifferent  forms, 
their  cytoplasm  is  clearer  and  hyaline,  and  contains  no 
reserve  material. 

The  nucleus  is  relatively  large,  and  instead  of  dividing 
into  trophic  and  kinetic  portions,  as  in  the  case  of  the 
indifferent  ookinet,  it  divides  into  a  male  and  a  female 
half.  The  latter  is  the  larger  but  undergoes  no  further 
development  and  eventually  disappears.  The  male  half 
of  the  nucleus  breaks  up  into  eight  smaller  nuclei,  which 
become  distributed  radially  in  the  peripheral  portion  of 
the  ookinet,  which  has  now  become  rounded  and  is 
termed  a  microgametocyte.  Prominences,  each  contain- 
ing one  of  the  nuclei,  grow  out  from  the  periphery  of 
the  microgametocyte  and  gradually  assume  the  shape  of 
a  trypanosome.  The  trophic  and  kinetic  portions  of  the 
contained  nucleus  become  separated  and  from  the  latter 
a  large  flagellum  is  produced  in  the  same  manner  as  in 
the  "  indifferent "  trypanosomes.  Eight  male  trypano- 
somes are  thus  formed,  they  become  free  and  very  active, 
the  motor  apparatus  being  much  more  developed  than 
in  the  indifferent  or  female  forms.  The  male  trypano- 
somes are  easily  distinguishable  by  their  minute  size  and 
great  activity.  They  undergo  no  further  development 
and  die  off  if  no  opportunity  for  copulation  occurs. 
Female  ookinets  are  the  largest  of  the  three  forms.     The 


SCHAUDINN  S   VIKWS  I27 

cytoplasm  is  dense,  the  nucleus  relatively  small,  and  the 
reserve  material  plentiful. 

Like  that  of  the  male,  the  nucleus  of  the  female 
separates  into  male  and  female  portions,  and  in  a  similar 
manner  the  male  portion  disappears,  while  the  female 
portion  divides  into  tropho-  and  kineto-nuclei,  the  last 
forming  a  flagellar  apparatus  in  the  same  manner  as  in 
the  indifferent  form.  The  female  trypanosome  thus 
formed  resembles  the  indifferent  form,  but  is  larger, 
rounder,  and  contains  much  more  reserve  material.  The 
flagellum  is  shorter  and  its  movements  are  much  less 
active.  The  female  form  never  divides  longitudinally, 
but  may  enter  a  gregariniform  stage,  and  on  account  of 
its  relatively  large  amount  of  reserve  material  it  can 
resist  unfavourable  influences  much  longer  than  can  the 
indifferent  form.  It  can  thus  survive  a  winter,  and  can 
infect  the  larvae  of  a  gnat  resulting  from  eggs  laid  in  the 
following  spring.  It  can  further  undergo  parthenogenesis 
and  thus  gives  rise  to  either  form  of  trypanosome. 

The  changes  so  far  described  occur  in  the  mosquito. 
When  the  mosquito  bites  an  owl,  all  three  forms  of 
trypanosomes  are  injected  into  the  bird's  blood.  The 
indifferent  trypanosomes  divide  by  longitudinal  fission 
into  very  small  forms,  which  become  attached  to  red 
corpuscles,  they  lose  their  flagella  and  have  the  appear- 
ance of  young  halteridia.  They  do  not  penetrate  the 
corpuscles  but  become  deeply  embedded  in  their  sub- 
stance, from  which  they  absorb  hzemoglobin,  and  in 
twenty-four  hours  exhibit  pigment  granules  in  their 
interior.  At  night  flagella  are  formed  and  the  halteridium 
becomes  a  trypanosome  again,  while  during  the  day  the 
halteridium  is  again  formed  and  is  again  attached  to  a 
red  corpuscle.  This  process  is  repeated  for  six  days, 
during  which  grow^th  occurs  and  full  size  is  attained. 
The  trypanosome  then  again  divides  into  small  forms 
and  the  process  just  described  is  repeated.  The  changes 
occur  chiefly  in  the  internal  organs,  especiall)^  in  the 
spleen    and    bone-marrow,    in    which   the    circulation    is 


128  TROPICAL   MEDICINE   AND    HYGIENE 

slower.  Schaudinn  suggests  that  the  considerable  lower- 
ing of  the  temperature  of  the  owl  which  occurs  at  night 
brings  about  the  changes  from  halteridium  to  the 
trypanosome  form. 

As  will  be  seen  later,  the  spirochaetae  were  also  con- 
sidered by  Schaudinn  to  be  the  result  of  rapid  longi- 
tudinal fission  of  trypanosomata  and  should  therefore  be 
included  in  the  flagellata. 

Leishman  had  early  pointed  out  the  close  resemblance 
of  the  Leishman-Donovan  bodies  to  degenerate  trypano- 
somes,  and  Rogers,  by  showing  that  in  artificial  media 
these  bodies  become  elongated  and  acquire  a  flagellum, 
has  proved  that  these  parasites  must  also  be  included  in 
the  flagellata. 

Considering  the  uncertainty  resulting  from  these  rapid 
advances  in  our  knowledge,  it  is  not  advisable  to  attempt 
to  classify  the  various  parasites  belonging  to,  or  probably 
belonging  to,  the  flagellata. 

The  list  appended  gives  the  main  groups  with  which 
we  are  concerned. 

(i)  Trypanosoma. — Body  elongated  and  terminating  as 
a  conical,  blunted,  or  pointed  extremity,  at  the  end  in 
which  the  centrosome  is  placed.  The  flagellum  passes 
along  the  length  of  the  body,  emerging  at  the  opposite 
end  to  that  from  which  it  arises.  A  portion  of  the  edge 
of  the  body  on  the  side  in  which  the  flagellum  lies  is 
thinned  out  with  a  motile  membraneous  edge,  the 
undulatory  membrane.  This  membrane  may  be  smooth 
or  crimped  up  and  is  largely  concerned  in  locomotion. 

(2)  Trypanoplasma  of  fish  and  Herpetomonas  differ  from 
the  Trypanosoma  in  that  there  is  no  undulatory  mem- 
brane, and  the  flagellum  or  the  flagella  emerge  from  the 
body  at  the  end  from  which  they  arise,  namely,  that  in 
which  the  centrosome  is  situated.  Many  of  the  Herpeto- 
monas are  parasitic  in  the  intestines  of  dipterous  insects, 
as  flies,  mosquitoes,  and  fleas. 

(3)  Leishman-Donovan  bodies  appear  to  be  a  resting 
stage  of  a  flagellate,  probably  of  Herpetomonas. 


TRYPANOSOMrASIS  I29 

(4)  Trcponciiui  have  lon,!^,  s[">ii-al  bodies,  and  are  very 
thin  and  cylindrical.  No  unduhitory  membrane  is 
present.  There  is  a  sinj^le  ilaj^ellum  at  each  end.  Multi- 
phcation  is  by  longitudinal  fission.  The  known  specimens 
stain  u^ith  basic  stains  with  diBiculty. 

To  this  group  is  now  assigned  the  organism  believed 
to  be  the  cause  of  syphilis,  and  described  as  the  Spirocliccta 
pallida,  and  probably  the  similar  organisms  found  in  yaws 
by  Castellani  and  in  granuloma  pudendi  by  Wise. 

(5)  Spirocliivtcv  are  elongated  spiral  bodies  with  no 
flagella.  Tiiey  are  usually  pointed  at  the  ends.  Accord- 
ing to  Schaudinn  there  is  an  elongated  nucleus,  and  mul- 
tiplication is  by  longitudinal  division.  Some  observers 
believe  that  multiplication  is  by  transverse  division,  and 
doubt  the  protozoal  nature  of  these  organisms. 

The  Spirodicvta  oberinelcri  and  S.  duttoni,  the  causal 
organisms  respectively  of  relapsing  fever  and  of  African 
tick  fever,  belong  to  this  group.  The  spirochastas  found 
commonly  in  the  mouth,  as  well  as  those  sometimes 
found  in  the  faeces,  and  those  described  in  the  lungs,  and 
by  some  believed  to  be  a  cause  of  bronchitis,  are  also 
members  of  this  group. 

Spirohactcria  are  organisms  that  are  not  protozoal 
but  which  either  constantly  or  occasionally  assume  a 
special  form,  such  as  the  vibrio  of  Asiatic  cholera. 
These  are  not  considered  in  this  part  of  the  work,  as 
they  definitely  belong  to  the  division  of  the  Protista  with 
vegetable  affinities. 

Trypanosomiasis. 
This  is  a  general  term  used  to  designate  the  diseases 
caused  in  the  higher  animals  by  the  presence  of  trypano- 
somes  in  the  blood.  Trypanosomes  are  found  in  many 
classes  of  animals,  but  while  they  cause  disease  in  most 
of  the  mammalia,  those  in  fish  and  amphibia  are,  as 
far  as  we  know,  harmless.  The  effects  of  trypanosomes 
vary,  both  according  to  the  species  of  the  parasite  and 
of  the  host. 
9 


130  TROPICAL   MEDICINE   AND    HYGIENE 

The  first  of  the  mammahan  trypanosomes  discovered 
was  that  of  the  rat,  T.  lewisi,  which  may  often  be  found 
in  enormous  numbers  in  rats.  They  appear  to  be 
harmless  in  adults,  but  in  young  rats  may  cause  fatal 
disease. 

Trypanosoma  bnicei  was  shown  to  be  definitely  patho- 
genic, and  was  proved  by  Bruce  to  be  the  cause 
of  the  fatal  "  fly  disease "  (nagana)  of  South  Africa. 
This  disease  is  rapidly  fatal  to  horses,  and  more  slowly 
causes  death  of  cattle,  monkeys,  and  dogs.  It  is  fatal  to 
rats  in  from  three  to  five  days. 

T.  evansi  causes  a  very  similar  disease  to*  nagana  in 
many  parts  of  the  East.  The  disease  is  known  in  India 
as  surra.  It  is  chiefly  fatal  to  horses,  but  cattle,  buffaloes, 
&c.,  though  less  affected,  often  harbour  the  parasites, 
and  may  die  after  a  prolonged  illness.  They  probably 
are  the  main  agents  in  spreading  the  disease  to  horses. 

T.  equiperdum  is  the  cause  of  the  peculiar  disease 
known  as  "  dourine."  It  is  of  special  interest,  as  the 
parasites  are  discharged  with  the  semen,  and  the  disease 
is  spread  from  males  to  females  by  coitus. 

There  are  in  human  trypanosomiasis  so  many  analogies 
with  syphilis  that  this  mode  of  communicating  disease 
is  of  theoretical  importance,  though  it  is  fairly  certain 
that  human  trypanosomiasis  is  not  spread  in  this  manner. 

T.  thieleri  occurs  in  cattle  in  South  Africa. 

T.  dimorphon. — Blunt-ended  trypanosomes  that  vary 
a  great  deal  in  size.  In  the  same  specimen  both  large 
and  small  are  usually  found  together.  Occurs  in  cattle 
and  horses,  and  most  of  the  laboratory  animals  are 
susceptible.  These  various  trypanosomes  are,  so  far  as 
we  know,  not  inoculable  in  man. 

One  human  trypanosome  is  well  known  ;  this  was  first 
found  by  Ford  in  Gambia,  and  was  first  identified  and 
described  by  Button  as  T.  gambiense.  A  second,  T.  cruzi, 
has  been  recently  discovered  in  South  America.  It  causes 
fever,  enlargement  of  spleen,  and  oedema  in  various  parts 
of  the  body.     It  may  be  fatal. 


131 


CHAPTER  XL 

HUMAN  TRYPANOSOMIASIS. 

A  DISEASE  due  to  the  presence  in  the  blood  of  T. 
ganibiense.  It  manifests  itself  as  a  long-continued  fever, 
at  first  of  a  severe  type,  but  later  a  low  form  of  hectic 
fever  and  associated  with  enlargement  of  the  lymphatic 
glands,  especially  the  cervical ;  evanescent  rashes,  and 
often  splenic  enlargement.  It  terminates  fatally  with 
cerebral  symptoms,  usually  of  the  form  long  known  as 
sleeping  sickness. 

Geographical  Distribution. — The  disease  is  only  known 
in  Tropical  Africa  as  an  indigenous  disease,  but  many 
cases  have  been  reported  in  Europe,  all  in  persons  who 
had  resided  in  Africa  within  the  last  few  years.  As 
judged  by  the  distribution  of  its  terminal  phase — sleeping 
sickness — the  disease  has  within  recent  years  been  spread- 
ing rapidly  across  Africa.  It  is  still  unknown  on  the 
Zambesi  and  south  of  it,  and  it  is  not  known  in  the 
neighbourhood  of  Lake  Nyasa  or  east  of  these  lakes. 
It  is  prevalent  throughout  the  Congo,  but  is  rare  on 
the  Gold  Coast,  in  Lagos,  and  in  Nigeria.  It  has  been 
introduced  into  the  neighbourhood  of  Victoria  Nyanza 
within  the  last  few  years,  and  now  extends  throughout 
that  district  and  down  the  Nile  some  200  miles.  There 
is  every  probability  that  it  will  become  more  widely 
diffused  in  Africa,  though  it  is  less  prevalent  in  some 
places,  such  as  Liberia,  where  at  one  time  it  was  common. 
The  intermediate  hosts  belong  to  the  genus  Glossiua,  and 
the  species  implicated  are  Glossina  palpalis  and  possibly 
G.fusca.  Glossinje  are  only  found  in  Africa  and  Arabia, 
and   suitable   species  to  act   as   alternate    hosts    are    not 


132  TROPICAL   MEDICINE   AND    HYGIENE 

present  in  South  Africa  and  South  America,  and  though 
the  disease  has  been  introduced  there  it  has  not  spread. 

Clinical  History. —  Little  is  known  as  regards  the  onset 
of  the  disease  in  man.  The  period  of  incubation  in 
monkeys  is  about  fourteen  days.  The  onset  in  man 
appears  to  be  often  confounded  with  malaria,  but  in 
some  cases  there  is  high  and  continued  fever  as  in 
typhoid,  and  in  some  cases  there  is  no  marked  fever. 
At  this  stage  there  appear  to  be  no  characteristic  symp- 
toms, but  sometimes  trypanosomes  are  found  abundantly 
in  the  blood. 

The  temperature  after  this  early  stage  may  fall  to 
normal,  and  remain  so,  but  even  in  these  cases  the 
diurnal  variation  is  usually  increased,  so  that  when  the 
temperature  is  taken  frequently,  though  it  may  rarely 
exceed  99"  F.,  there  may  be  a  variation  at  different  times 
of  the  day  of  as  much  as  2°  F.  More  frequently  there 
is  slight  irregular  fever,  the  temperature  rising  to  100°  or 
loi'^^  F.  every  day.  At  times,  in  such  cases,  there  will  be 
definite  pyrexia,  the  temperature  rising  to  103°  or  104°  F., 
or  even  more,  for  several  days,  falling  gradually  to  normal 
or  a  little  above  it. 

Some  of  the  lymphatic  glands  are  soon  found  to  be 
enlarged  and  are  soft  to  the  touch.  They  are  not  acutely 
painful  but  are  tender  on  pressure.  The  glands  at  the 
base  of  the  neck  are  those  most  commonly  enlarged. 

In  Europeans  a  rash  is  usually  present.  It  is  evanes- 
cent but  appears  as  erythematous  rings  surrounding  an 
area  sometimes  slightly  discoloured  by  blood  pigments.. 
This  discoloration  may  amount  to  an  actual  bruised 
appearance.  The  rings  are  not  raised  to  the  touch.  The 
chest,  abdomen  and  covered  portions  of  the  body  are  the 
usual  sites  for  this  eruption,  but  it  may  occur  on  any 
other  parts  of  the  body,  such  as  the  forehead  and  face. 
There  is  progressive  muscular  weakness,  some  loss  of 
flesh,  and  some  anaemia.  Even  in  the  early  stages  a 
slight  blow  may  cause  prolonged  muscular  pain — 
Grissoli's  symptom.     The    cardiac   action    is   very   rapid 


HUMAN   TRYPANOSOMIASIS  I33 

and  unduly  subject  to  irregularities  as  a  result  of  slight 
exertions.  A  line  muscular  tremor  is  often  perceptible 
in  the  hands  in  late  stages.  The  appetite  is  good,  and 
unless  there  is  much  pyrexia  the  tongue  is  moderately 
clean  and  the  bowels  regular. 

The  disease  runs  a  very  chronic  course,  and  with  the 
subsidence  of  the  fever  the  general  condition  shows  some 
improvement,  and  the  patient  may  be  able  to  go  about 
his  work  and  believes  that  he  is  recovering.  This  con- 
dition may  last  for  two  or  three  years.  During  this  period 
trypanosomes  will  only  be  found  in  the  blood  after 
prolonged  search  :  they  may  be  more  abundant  during 
a  pyrexial  period  in  those  cases  in  which  definite  attacks 
of  fever  recur.  They  are  much  more  readily  found  in 
the  soft  enlarged  glands,  but  in  old  hard  glands,  though 
they  be  still  enlarged,  the  trypanosomes  may  not  be  more 
numerous  than  in  the  peripheral  blood. 

Injections  of  considerable  amounts,  2  c.c.  or  more,  of 
the  blood  of  such  patients  into  monkeys  or  other  sus- 
ceptible animals  will  result  in  the  infection  of  such 
animals,  and  the  trypanosomes  can  be  found  in  number  in 
their  blood,  and  the  animals  will  die  shortly  after.  Rats 
may  be  infected  in  this  way,  but  the  results  are  uncertain, 
and  the  period  of  incubation  may  be  prolonged  to  months. 

Sooner  or  later  in  a  patient  who  may  have  been  free 
from  fever,  and  in  whom  the  presence  of  parasites  may 
only  be  shown  by  the  infection  of  animals  with  the 
patient's  blood,  terminal  cerebral  symptoms  supervene. 

The  cerebral  symptoms  vary  in  character ;  they  may 
take  the  form  of  a  rapidly  fatal  coma  or  of  a  series  of 
epileptiform  convulsions,  or  of  the  progressive  lethargic 
condition  known  as  sleeping  sickness  or  negro  lethargy. 

In  this  condition,  which  is  the  most  common  termina- 
tion of  the  disease,  the  patient  passes  into  a  peculiarly 
lethargic  state,  so  that  while  the  total  amount  of  sleep 
obtained  may  be  little  above  normal  he  is  always  drowsy, 
and  frequently  falls  asleep  even  at  meals  or  when  in  the 
act  of  performing  some  ordinary  occupation.     Before  the 


.134  TROPICAL   MEDICINE   AND   HYGIENE 

onset  of  these  symptoms  there  is  usually  marked  fine 
tremor  and  dull  headache.  The  temper  is  frequently  un- 
certain, and  there  may  be  mental  irritability.  This  irrita- 
bility, as  the  disease  progresses,  becomes  more  marked 
and  mental  deficiency  occurs.  There  is  a  general  aspect 
of  misery  about  the  patient  and  he  is  apt  to  be  neglectful 
of  his  person,  and  dirty  and  careless  in  his  habits. 

Muscular  weakness  is  extreme,  and  unless  the  patient 
is  regularly  fed  he  rapidly  emaciates  and  dies,  partly  of 
starvation.  Even  when  well  fed  and  carefully  nursed 
there  is  rapidly  progressive  emaciation.  The  termination 
of  the  disease  may  be  associated  with  diarrhoea,  or  the 
patient  dies  comatose. 

Diagnosis. — The  disease  may  be  mistaken  in  the  early 
stages  for  malaria  and  typhoid  fever  and  possibly  pell- 
agra. In  the  later  with  any  of  the  chronic  forms  of 
intermittent,  remittent,  or  "  low  fever,"  such  as  kala-azar. 

As  the  disease  is  confined  to  Tropical  Africa,  suspicion 
may  be  excluded  in  patients  who  have  not  resided  in  that 
country.  The  presence  of  enlarged  gfands  and  the 
fugitive  circinate  eruptions  are  of  great  value  in  the 
diagnosis. 

Certainty  can  only  be  obtained  by  finding  trypanosomes 
in  the  blood  or  fluid  obtained  by  hypodermic  puncture 
of  one  of  the  enlarged  glands,  or  by  the  results  of  the 
injection  of  the  blood  into  monkeys  or  other  susceptible 
animals,  but  with  some  of  these,  such  as  rats,  the  period 
of  incubation  may  be  indefinitely  prolonged. 

In  the  terminal  stage  the  epileptiform  convulsions  and 
the  comatose  condition  might  readily  be  mistaken  for 
other  diseases.  When  this  stage  shows  the  peculiar 
lethargy  of  sleeping  sickness  mistakes  could  hardly 
occur.  When  cerebrospinal  symptoms  have  set  in  try- 
panosomes may  not  be  found  in  the  blood,  but  only  in 
the  cerebrospinal  fluid.  This  should  be  drawn  off  by 
lumbar  puncture,  and  centrifugalized,  as  the  parasites  are 
usually  scanty. 

Prognosis.  —  The  terminal   stage,   sleeping   sickness,    is 


HUMAN    TRYPANOSOMIASIS  I35 

invariably  fatal.  The  earlier  sta^L^es  of  the  disease,  when 
there  is  merely  a  trypanosome  infection  of  the  blood  and 
lymphatic  system,  are  amenable  to  treatment,  and  there 
is  good  reason  to  believe  that  complete  and  permanent 
recovery  may  ensue. 

The  disease  is  a  serious  one,  and  the  prognosis,  even 
when  all  the  symptoms  have  disappeared,  and  the 
parasites  cannot  be  found  in  either  glands  or  blood, 
must  be  guarded,  as  cerebrospinal  symptoms  may  occur 
years  after  the  original  infection. 

Pathological  Anatomy. — Little  is  known  of  the  patho- 
logical anatomy  of  the  early  stages  of  the  disease  in  man. 
In  monkeys  and  the  lower  animals  the  condition  is  mainly 
one  of  visceral  congestion,  but  enlargement  of  the  spleen 
and  intense  congestion,  sometimes  h^emorrhagic  of  the 
lymphatic  glands  and  extreme  congestion  of  the  brain  are 
also  met  with. 

In  sleeping  sickness  there  is  formation  of  round  cells 
in  the  perivascular  spaces  of  the  cerebral  capillaries, 
closely  resembling  that  found  in  general  paralysis  of  the 
insane. 

Treatment. — The  drugs  most  distinctly  useful  in  malaria, 
quinine  and  methylene  blue,  have  no  effect  in  this  disease 
and  do  not  alleviate  the  symptoms  or  reduce  the  number 
of  trypanosomes.  Arsenic  long  had  some  reputation 
in  the  treatment  of  the  early  stages  of  sleeping  sickness, 
and  experiments  with  various  trypanosomie  infections  in 
lower  annuals  showed  that  this  drug  had  a  decided 
controlling  effect,  and  that  the  number  of  parasites  could 
be  reduced,  and  life  much  prolonged  by  its  administra- 
tion. The  effects  were  not  permanent ;  if  the  arsenic  were 
pushed  the  animals  died  from  arsenical  poisoning,  whilst 
if  given  in  smaller  amounts  the  trypanosomes  became 
tolerant  of  the  drug  and  the  animals  died  of  trypanoso- 
miasis. 

In  human  trypanosomiasis  it  was  soon  found  that  only 
a  few  persons  could  tolerate  arsenic  given  by  the  mouth 
in  sufficient  quantities   for  the  parasites  to   be    affected. 


136  TROPICAL   MEDICINE   AND   HYGIENE 

Various  forms  of  injection  of  arsenic  were  tried,  cacody- 
lates  and  the  like,  but  arsenic  in  the  form  of  atoxyl 
appears  to  be  both  the  safest  and  most  promising.  In  the 
lower  animals  very  large  doses  seemed  to  effectively  con- 
trol the  disease  without  producing  arsenical  poisoning. 
In  man  smaller  doses  have  to  be  used  or  arsenical  poison- 
ing will  result.  The  most  successful  method  is  to  use 
a  freshly  made  10  per  cent,  solution  of  atoxyl  in  normal 
saline.  The  solution  must  be  sterilized  before  use  and 
injected  whilst  still  warm  into  one  of  the  large  muscles, 
such  as  the  gluteus  maximus  :  20  minims  every  alternate 
day  can  always  be  borne,  and  the  dose  should  be 
gradually  increased  and  given  more  frequently  till  a 
decided  effect  is  produced,  2^  to  3  grains  of  atoxyl  will 
usually  suffice  ;  in  some  persons  symptoms  of  poisoning 
are  produced  by  25  minims,  but  a  larger  dose  is  better 
and  in  most  cases  can  be  taken.  In  some,  70  minims  or 
more  may  be  well  borne ;  30  minims  every  other  day 
appears  to  be  an  effective  dose,  the  parasites  diminish  in 
number  and  ultimately  cannot  be  found.  The  glands 
become  small  and  hard,  the  temperature  normal,  and  the 
eruption  ceases  to  appear.  The  general  health  also  is 
completely  restored.  Relapses  occur,  particularly  if  there 
be  any  intercurrent  disease.  The  atoxyl  treatment  should 
be  continued  for  at  least  a  year  after  the  symptoms  have 
disappeared.  Sufficient  time  has  not  yet  elapsed  for 
certainty  as  to  the  completeness  and  permanency  of  the 
recovery,  and  particularly  whether  all  possibility  of  the 
recurrence  of  the  cerebral  symptoms  or  of  sleeping 
sickness  has  been  obviated. 

It  is  somewhat  unfortunate  that  a  different  line  of  treat- 
ment has  been  adopted  on  a  large  scale.  This  plan, 
introduced  by  Koch,  was  to  use  large  doses  and  repeat 
them  a  fortnight  later.  The  immediate  effects  were  good, 
so  much  so  that  the  method  was  widely  advertised,  and 
has  been  extensively  employed.  Further  experience  has 
shown  that  the  effects  are  temporary,  relapses  the  rule, 
and  optic  atrophy  common.  These  results  have  to  some 
extent  discredited  the  use  of  atoxyl. 


HUMAN    TRYPANOSOMIASIS  I  37 

The  attempt  to  treat  many  diseases  by  a  few  heroic 
doses  has  often  failed,  as  in  syphilis  by  mercury,  and 
malaria  by  quinine,  whilst  the  same  drugs  in  moderate 
doses  continued  for  a  long  time  have  a  permanent  bene- 
ficial effect,  and  the  same  appears  to  hold  good  with 
atoxyl  in  trypanosomiasis.  Alternate  treatment  with 
atoxyl  and  mercury  has  been  advocated,  but  the  results 
in  man  have  been  no  better  than  with  atoxyl  alone. 

Injections  of  preparations  of  antimony  have  a  more 
powerful  effect  on  the  trypanosomes  than  atoxyl  or  any 
other  arsenical  preparations,  but  the  antimony  prepara- 
tions used  cause  much  pain  and  local  gangrene  unless 
very  dilute. 

Nursing. — No  special  precautions  are  required.  The 
disease  is  a  chronic  one  and  good  feeding  is  necessary. 
On  account  of  the  cardiac  condition  sudden  movements 
or  exertion  on  the  part  of  the  patient  must  be  discouraged. 
When  the  general  condition  of  the  patient  permits  it  he 
should  be  allowed  to  live  an  ordinary  healthy  life.  But 
over-fatigue  and  any  risk  of  intercurrent  disease  must 
be  carefully  guarded  against. 

When  taking  atoxyl  or  any  other  preparation  of  arsenic, 
any  digestive  disturbance  such  as  nausea,  vomiting,  or 
abdominal  pains  must  be  carefully  noted.  Any  com- 
plaint of  dryness  of  the  mouth,  and  pain  or  irritation  of 
the  eyes,  must  also  be  reported. 

Increasing  muscular  tremor,  headache,  and  disturbed 
sleep  are  premonitory  signs  of  the  onset  of  sleeping 
sickness.  When  this  supervenes,  all  that  can  be  done  is 
to  feed  the  patient  at  regular  intervals,  and  to  keep  him 
clean,  warm  and  comfortable.  There  is  no  object  in  en- 
deavouring to  prevent  him  from  sleeping. 

Etiology. — There  are  certain  points  of  analogy  between 
trypanosomes  and  some  cases  of  S3'philis.  In  both  there 
is  a  latent  period  followed  by  a  more  or  less  marked 
febrile  stage,  and  associated  with  glandular  enlargement 
and  cutaneous  eruptions  and  terminating  in  the  formation 
of  diffuse  lymphoid  growths  around  the  cerebral  vessels. 


138  TROPICAL   MEDICINE   AND   HYGIENE 

The  mode  of  propagation  of  one  of  the  trypanosome 
diseases  in  the  horse  is  by  sexual  intercourse.  With 
human  trypanosomiasis  the  disease  is  not  spread  in  this 
manner,  but,  as  far  as  is  known,  by  the  bites  of  certain 
flies  belonging  to  the  genus  Glossina. 

From  the  distribution  of  the  disease,  and  the  corre- 
sponding distribution  of  the  flies,  G.  palpalis  is  beheved 
to  be  the  important  carrier,  whilst  G.  fiisca  and  possibly 
G.  tachinoides  may  also  be  carriers.  The  commonest  of 
the  tsetse-flies,  G.  morsitans,  though  it  carries  the  trypano- 
some of  nagana,  is  probably  not  a  carrier  of  T.  ganibiense. 

The  Glossinas  are  a  genus  limited  to  Africa  and  the 
shores  of  the  Arabian  Gulf,  and  are  easily  distinguished 
from  other  biting  flies. 

They  are  dipterous  insects,  and  closely  resemble  many 
of  the  Muscidae,  but  are  distmguished  by  the  long,  straight 
proboscis,  by  the  arista  or  spine  which  arises  from  the 
third  joint  of  the  antennae  being  plumose  on  the  one 
side  only,  by  the  palps  being  the  same  length  as  the 
proboscis  and  grooved  on  the  inner  sides,  so  that  together 
the  two  palpi  form  a  sheath  for  the  proboscis.  There 
are  hairs  only  on  the  convex  side  of  the  arista  compound. 
The  wings  are  crossed,  so  that  when  at  rest  their  tips 
overlap  each  other — "scissor"  wings  —  and  project 
beyond  the  abdomen.  The  fourth  longitudinal  vein  is 
bent  twice,  once  to  meet  the  transverse  vein,  and  a 
second  time  to  approximate  tothe  third  longitudinal. 

Glossinae  are  pupiparous,  the  larvae  attain  their  full 
growth  in  the  ovary,  and  after  being  passed  do  not  feed 
but  pass  into  the  ground  and  become  pupae. 

G.  palpalis  can  be  easily  distinguished  from  other 
common  Glossinae,  as  the  last  four  joints  of  the  hind  legs 
are  entirely  black.  Two  other  species  have  this  character, 
G.  pallicera  and  G.  maculata,  whilst  in  G.  tachinoides  the 
last  four  joints  though  black  are  not  entirely  so.  The 
commoner  species,  G.  morsitans,  has  only  the  last  two 
joints  of  the  hind  legs  black. 

Without  going  into  detail,  then,  Glossinas  are  flies  which, 


HUMAN    TKYPANOSOMIASIS 


J  39 


when  alive,  are  readily  recognized  by  the  slraif^ht,  long 
proboscis  projecting  out  in  front  of  the  head,  and  i)y  the 
crossed  position  of  the  wings  of  the  insect  when  at  rest. 
These  wings  are  always  longer  than  the  abdomen,  and 
projecting  beyond  it  give  the  insect  the  appearance  of 
being  longer  than  it  really  is  (lig.  33). 

Glossinas  bite  mainly  in  the  daytime,  though  some  species 
also  bite  at  night.  The  bite  is  painful  at  the  time,  feeling 
more  like  a  sharp  sting,  but  not  producing  any  subsequent 
local   effects.      They  will    bite  a  man    or    other   animal 


Fig.  33. — Glossina  morsitans. 


while  he  is  in  motion,  and  seem  to  bite  almost  as  soon 
as  they  alight  on  him.  G.  palpalis  is  often  found  in 
boats  and  canoes,  sheltering  under  the  thwarts.  Very 
frequently  it  will  crawl  out  and  bite  the  legs,  and  in  other 
cases,  as  they  often  keep  low,  will  alight  on  the  legs  and 
bite,  whereas  G.  morsitans  more  frequently  attacks  the 
upper  part  of  the  body,  the  head  or  neck. 

They  are  usually  found  in  narrow  belts  near  water  on 
the  edge  of  forest  land,  and  may  in  such  situations  be 
present  in  large  numbers  for  a  few  hours,  whilst  at  other 


140  TROPICAL   MEDICINE   AND   HYGIENE 

times  few  or  none  may  be  found.  They  are  also  found  in 
well-wooded  country,  in  forest  clearings,  and  near  forests. 
The  larvae  are  deposited  in  the  neighbourhood  of  rotting 
vegetation,  and  particularly  near  the  roots  of  certain 
plants,  such  as  bananas,  as  well  as  many  other  plants 
and  trees.  The  pupae  are  usually  found  in  banks 
covered  with  trees  near  open  water,  lakes,  or  streams. 
Extensive  clearings,  therefore,  form  an  important  part  of 
prophylaxis. 

By  the  formation  of  such  clearings  and  the  burning  off 
of  refuse  vegetation  in  the  vicinity  of  settlements,  the 
actual  habitations  may  be  kept  clear  of  these  flies.  It  has 
been  suggested  that  keeping  and  breeding  fowls,  or  the 
importation  of  jungle  fowls  from  India,  might  aid  in 
the  destruction  of  such  larvae.  It  is  doubtful,  however, 
whether  such  fowls  would  have  any  chance  of  continued 
existence  at  any  distance  from  human  habitations,  and 
the  larvae  are  deposited  away  from  the  uncleared  tracts 
or  in  plantations. 

More  hope  of  the  destruction  of  the  flies  in  their  adult 
form  may  be  entertained  by  the  introduction  or  cultiva- 
tion of  insectivorous  insects  and  other  animals,  such  as 
dragon-flies.  Koch  believes  that  their  most  important 
source  of  food  is  the  crocodile,  and  advocates  the 
extermination  of  that  reptile.  Protection  from  the  bites 
of  flies  is  very  difficult,  not  only  fly-proof  houses  must 
be  made,  but  fly-proof  clothing  must  be  worn  when  out- 
side such  houses.  Such  measures  should  be  taken  when 
living  in  an  endemic  area  close  to  native  settlements 
where  sleeping  sickness  is  prevalent. 

Biting  flies  belonging  to  other  families  are  not  to  be 
altogether  ignored,  as  the  trypanosomes  of  Asia  are 
carried  by  some  of  these,  such  as  Stomoxys.  Attention  in 
Africa  has  been  almost  entirely  directed  to  Glossinae. 

It  is  not  known  how  the  Glossinae  convey  trypanoso- 
miasis. There  is  direct  evidence  that  occasionally  they 
convey  the  parasites  by  feeding  first  on  an  infected  animal 
and   very  shortly   after   feeding    on   another   susceptible 


HUMAN   TRYPANOSOMIASIS 


141 


animal.  Such  transmission  is  direct.  Usually  attempts 
at  transmission  in  this  manner  fail,  and  Kleine  has 
recently  shown  that  flies  again  become  infective  eighteen 
days  or  more  after  they  have  fed  on  infected  animals. 

All  attempts  to  demonstrate  a  definite  cycle  of  develop- 
ment of  trypanosomes  in  the  Glossin^c  have  failed.     The 


Fig.  34. 


enquiry  is  difficult  because  flagellates  are  so  common  in 
the  alimentary  canal  of  flies.  Minchin  has  suggested  that 
the  encysted  trypanosomes  which  he  found  in  the  intes- 
tines of  Glossinae  were  the  developmental  stage  and  that 
the   trypanosomes,  after    development,  \vere   passed  per 


142  TROPICAL   MEDICINE   AND   HYGIENE 

reduin  and  possibly  subsequently  deposited  on  food 
which  was  devoured  by  man,  who  then  became  infected. 
The  biting  method  of  infection  appears  to  be  the  more 
probable,  and  the  contamination  method  has  not  met  with 
much  support.  In  mammals  they  multiply  asexually  by 
longitudinal  division  (fig.  34).  Small  resting  forms, 
according  to  some  observers,  may  be  produced. 
•  Prophylaxis  amongst  Europeans  is  comparatively 
simple.  Districts  where  sleeping  sickness  is  prevalent 
should  be  avoided  as  much  as  possible  European 
habitations  should  not  be  near  water  nor  placed  where 
Glossinae  are  plentiful.  The  houses  should  be  fly-proof, 
and  as  far  as  possible  from  native  settlements. 

When  travelling  fly-proof  clothing  should  be  worn  and 
boots  after  the  style  of  mosquito  boots  ;  veils  also  should 
be  worn  and  loose  gloves. 

Prophylaxis  for  natives  is  very  difficult,  (i)  Segregation 
of  the  infected;  (2)  deportation  of  the  non-infected  to 
a  fly-free  area  ;  (3)  destruction  of  the  fly  along  ordinary 
routes  of  travel ;  (4)  treatment  of  infected  persons  to 
reduce  the  number  of  trypansomes  where  it  is  impossible 
to  isolate  them  in  a  fly-free  country,  are  the  most 
promising  measures. 

(i)  Segregation  of  the  infected  is  not  likely  to  be 
thorough,  as  the  symptoms  are  for  a  long  time  indefinite 
and  the  prolonged  search  of  the  blood  necessary  to  find 
trypanosomes  is  impracticable  for  a  large  collection  of 
persons. 

Examination  for  enlarged  glands  is  not  conclusive,  as 
glandular  enlargement  is  so  common  from  other  causes. 
A  combination,  however,  of  the  examination  for  enlarged 
glands  and  microscopic  examination  of  the  fluid  obtained 
by  gland  puncture  is  of  value  in  preventing  the  introduc- 
tion of  diseased  persons  into  a  community.  The  segre- 
gation camps  must  be  in  a  district  free  from  the  fly  or 
they  may  form  a  focus  for  the  spread  of  infection. 

(2)  Deportation  of  the  whole  of  uninfected  population 
to  a  fly-free  area  is  the  most  satisfactory  of  the  present 


HUMAN    TRYPANOSOMIASIS  I43 

methods.  The  old  station  must  he  Ininit,  the  gardens 
destroyed,  and  patrols  established,  or  some  of  the  people 
will  return  and  may  become  infected. 

(3)  Destruction  of  the  fly  along  known  trade  routes 
is  important.  The  points  of  special  danger  are  ferries, 
fords  and  watering  places,  as  at  such  places  many 
travellers  pass  and  the   fly  is  often  present. 

Extensive  clearing  of  the  jungle  along  the  banks  of 
the  rivers  for  100  yards  from  the  edge  of  the  water  and 
on  each  side  of  the  path  in  the  vicinity  of  water  will 
greatly  reduce  the  number  of  flies  present. 

(4)  Treatment  with  atoxyl  will  greatly  reduce  the 
number  of  trypanosomes  present  in  the  blood  and  thereby 
chminish  the  probability  of  infection  of  the  fly,  even  in 
cases  where  the  course  of  the  disease  is  little  afifected. 


144 


CHAPTER  XII. 

KALA-AZAR.      KALA-DUKH.      DUM-DUM    FEVER. 
TROPICAL  SPLENOMEGALY. 

Definition. — A  chronic  infective  febrile  disease  due 
to  a  flagellate  protozoal  organism  found  in  its  resting, 
non-flagellate  form  in  the  spleen,  liver,  intestines  and 
other  organs.  The  disease  is  characterized  by  long- 
continued  fever,  enlargement  of  the  spleen  and  liver, 
wasting,  debility  and  anaemia,  and  by  a  very  high 
mortality.     It  occurs  both  endemically  and  in  epidemics. 

Geographical  Distribntion. — The  principal  seat  of  kala- 
azar  is  Assam,  in  parts  of  which  it  has  long  been  prevalent, 
though  it  was  first  mentioned  in  1882.  Its  name,  signi- 
fying the  "  black  disease,"  refers  either  to  the  terrible 
mortality  attending  the  epidemics  which  for  many  years 
devastated  district  after  district  of  Assam,  or  to  the  dark- 
ening of  the  skin  observed  in  many  of  those  suffering 
from  it. 

Epidemics  have  occurred  in  Lower  Bengal,  where  the 
disease  is  also  endemic,  and  the  name  "  Dum-Dum  fever  " 
was  given  to  attacks  of  it  contracted  at  this  station  by 
British  soldiers,  many  of  whom  have  died  of  it  in 
England. 

Kala-azar  also  occurs  in  Madras,  and  sporadic  cases 
have  been  met  with  in  Bombay  and  other  parts  of  India, 
also  in  Burmah  and  Ceylon.  Cases  have  also  been 
described  as  occurring  in  China,  the  Straits  Settlements, 
the  Phihppines,  Panama,  Northern  Africa,  and  the  Soudan. 

The  population  of  some  of  the  places  named  is  drawn 
from  so  many  sources,  that  it  is  not  possible  to  say  at 
present  whether  the  disease  is  endemic  in  them  or  not. 


KALA-AZAR  I45 

Clinical  Course. — Tlic  cliniciil  picture  of  a  case  of  kala- 
azar  of  some  months'  duration  is  very  strikinj^.  The 
patient,  even  if  up  and  about,  is  obviously  ill.  He  is  a 
wretchedly  thin,  tired-looking  man,  with  a  big  abdomen 
and  shrunken  limbs,  and  complains  of  having  had  fever 
off  and  on  for  months,  and  that  in  spite  of  quinine  and 
various  other  medicines  he  has  become  gradually  thinner 
and  weaker,  while  his  abdomen  has  got  bigger  and  bigger. 

A  very  slight  examination  of  the  patient's  distended 
abdomen  will  show  that  his  spleen  is  enormously  en- 
larged, that  his  liver  is  also  increased  in  size,  and  perhaps 
that  there  is  a  little  ascites  present ;  possibly  the  superficial 
abdominal  veins  will  be  noticeably  prominent,  and  if 
attention  be  turned  to  the  feet  some  oedema  of  the  ankles 
and  dorsum  will  be  found.  Besides  being  thin,  the 
patient  is  also  anaemic,  and  his  skin,  especially  that  of 
the  face,  is  darkened  or  pigmented.  His  hair  is  dry  and 
lustreless  and  may  fall  out  in  quantities,  leaving  him 
almost  bald.  He  is  very  easily  tired  and  any  little  exer- 
tion causes  breathlessness.  His  intellect  is  generally 
■clear,  and  he  may  make  little  complaint  except  of  his 
gradually  increasing  weakness  and  wasting ;  he  may,  or 
may  not,  complain  of  present  fever,  but  even  in  its 
absence  may  say  that  he  is  disturbed  at  nights  by  violent 
■sweats,  but  for  which  he  probably  sleeps  well. 

Not  infrequently,  however,  patients  at  this  stage  of  the 
■disease  suffer  from  attacks  of  epistaxis,  or  of  bleeding 
from  the  gums  or  from  other  mucous  surfaces.  Some- 
times, too,  petechiae  appear,  more  commonly  in  the 
axillae  than  elsewhere.  Attacks  of  bronchitis  or  sore 
throat  are  not  uncommon.  Less  common  symptoms, 
but  of  sufficient  frequency  to  require  mention,  are  jaun- 
dice, rheumatic  pains  in  the  joints,  and  ulcers  on  the 
skin. 

It  is  noteworthy  that  in  spite  of  their  serious  illness  the 

appetite  of  patients    suffering    from  kala-azar  is  usually 

very  good,   sometimes   it  is  even  voracious,   leading   to 

■over-eating  and  consequent  dyspepsia.     But  for  this  and 

10 


146  TROPICAL   MEDICINE   AND   HYGIENE 

for  a  rather  undue  degree  of  thirst,  there  are  usually  no 
symptoms  referable  to  the  digestive  system  until  later  in 
the  disease.  The  tongue  is  clean  and  the  bowels  are 
inclined  to  be  constipated.  Later  on,  however,  diarrhoea 
or  dysentery  sets  in,  the  latter  being  the  most  common 
immediate  cause  of  death.  Less  commonly  the  patient 
dies,  after  several  months  of  illness,  of  asthenia,  or  some 
intercurrent  disease,  such  as  pneumonia,  carries  him  off. 

In  places  where  the  disease  is  epidemic,  patients  will 
not  infrequently  be  met  with  who  say  that  several  of  their 
relations  have  died  of  a  similar  disease  within  a  year  or  two. 

The  incubation  period  of  kala-azar  is  not  definitely 
known,  though  it  is  probably  long,  some  months  having 
elapsed  in  many  instances  between  the  departure  of 
patients  from  infected  places  and  the  onset  of  symptoms- 
Considerable  difficulty  in  determining  the  incubation 
period  arises  from  the  circumstance  that  sometimes  the 
onset  of  the  disease  is  very  insidious,  while  in  many  cases 
the  earliest  symptoms  are  mistaken  for  those  of  malarial 
fever,  or  of  typhoid  fever. 

Three  stages  of  the  disease  are  commonly  recognized  : 
those  of  the  initial  fever,  of  the  secondary  low  fever,  and 
of  cachexia. 

These  stages  are  not  sharply  marked  off  from  one 
another,  for  the  acute  pyrexial  attacks  of  the  initial  period 
become  gradually  less  severe,  until  they  emerge  into  the 
chronic  irregular  fever  of  the  secondary  period,  and  after 
this  has  persisted  for  some  months  the  cachectic  con- 
dition is  established.  There  is  a  gradual  loss  of  ground 
throughout  the  course  of  the  disease,  though  periods  of 
temporary  improvement  may  occur. 

The  initial  fever  may  resemble  typhoid  fever  (fig.  35),  or,, 
in  other  cases  malarial  remittent  fever,  commencing  with 
chills,  or  less  commonly  with  a  rigor,  mounting  to  a 
considerable  height,  and  after  several  hours  falling  several 
degrees,  the  fall  being  accompanied  by  profuse  perspira- 
tions. These  febrile  attacks  recur  daily.  At  first  the 
type  is  remittent,  but  may  soon. become  intermittent,  the. 


KALA-AZAK 


147 


daily  range   of  temperature    being    c(>nsideral)le,    varying 
between  97°  and  103°  F.  (fig.  36). 

The  rise  of  temperature  usually  occurs  in  the 
evening,  but  not  uncommonly  there  is  a  double  or  even 
a  treble  rise  and  fall  in  the  twenty-four  hours.  Some- 
times there  are  short  periods  of  apyrexia,  followed  by 
further  outbursts  of  fever. 


TIME 

M 

E 

M 

E 

M 

E 

M 

E 

M 

E 

M 

c 

M 

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M 

E 

M 

E 

M 

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f" 

104 

103 

1  02 

1  0  1 

100 

99 

98 

97 

^ 

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/^ 

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\l\ 

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It 







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r 

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Fig.  35. — Kala-azar.     Simulating  typhoid. 


Fig.  36. — Kala-azar.     Later  showing  intermittent  type. 


After  the  fever  has  lasted  a  short  time,  the  spleen 
becomes  enlarged  and  tender ;  enlargement  and  tender- 
ness of  the  liver  also  occur,  but  are  less  marked.  Wast- 
ing, anemia,  and  debility  are  early  symptoms  of  the 
disease,  and  sometimes  darkening  of  the  skin  is  observed 
at  this  stage. 


148 


TROPICAL   MEDICINE   AND    HYGIENE 


Headache  sometimes  accompanies  the  fever,  but  there 
is  very  httle,  if  any,  digestive  disturbance,  the  tongue 
remains  clean,  and  the  appetite  good,  except  in  cases 
where  high  fever  has  persisted  for  some  time.  The  first 
stage  usually  lasts  about  a  month,  but  the  duration  may 
vary  from  ten  days  to  two  months. 

It  is  followed,  either  directly  or  after  an  interval  of 
apparent  health,  by  a  stage  in  which  low  fever  persists 
for  weeks  or,  more  frequently,  for  months.  Sometimes 
the  course  of  this  secondary  fever  is  very  irregular.  It  is 
rarely  high,  though  there  may  be   occasional  attacks  of 


TIME 

M 

E 

M 

E 

M 

E 

M 

E 

M 

E 

M 

ri"^ 

M 

F 

M- 

E 

wT 

1? 

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104 

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102 

1  01 

100 

9  9 

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V 

Fig.  37. — Kala-azar.     Undulating  type. 


high  fever,  lasting  for  some  days,  while,  on  the  other 
hand,  there  may  be  days  or  weeks  of  apyrexia  (fig.  37). 
In  some  cases  the  course  of  the  fever  may  be  remarkably 
regular,  the  temperature  rising  and  falling  to  exactly  similar 
points  at  the  same  hours  day  after  day  for  weeks.  Fre- 
quently also  the  course  of  the  temperature  chart  shows 
a  double  daily  rise  and  fall.  The  fever  at  this  state  often 
causes  but  little  discomfort,  and  but  for  profuse  sweating 
the  patient  may  be  unaware  that  he  has  any.  Sweating, 
especially  at  night,  may,  however,  occur  without  any  rise 
in  the  temperature. 

The  liver  and  spleen  continue  to  enlarge,  the  latter 
often  attaining  enormous  dimensions.  Emaciation, 
anaemia  and  debility  are  progressive  until  the  condition 


KALA-AZAk  149 

iilready  described  is  attained,  and  the  stage  of  cachexia 
supervenes. 

As  the  end  approaches  the  patient's  condition  is 
wretched  in  the  extreme.  He  is  terribly  emaciated,  and 
so  weak  that  he  can  hardly  move,  he  suffers  from 
diarrhoea  or  dysentery,  though  his  appetite  may  be 
ravenous  to  within  a  day  or  two  of  death.  By  this  time 
the  fever  may  have  given  place  to  subnormal  tempera- 
ture, and  the  spleen  and  liver,  though  still  considerably 
enlarged,  may  be  smaller  than  formerly.  Death  is  most 
commonly  due  to  dysentery,  which  appears  to  be  an 
integral  feature  of  the  last  stage  of  the  disease,  rather  than 
an  added  complication.  As  already  stated,  however, 
patients  sometimes  die  from  mere  asthenia,  while  not 
uncommonly  death  is  due  to  some  intercurrent  disease, 
of  which  lobar  pneumonia,  phthisis,  and  cancrum  oris 
are  those  most  frequently  met  with. 

The  duration  of  the  disease  varies  from  three  or  four 
months  to  two  years,  but  is  most  commonly  a  year  or 
eighteen  months.  Of  this  period  the  stage  of  initial  fever 
lasts  a  month  or  two,  and  that  of  low  fever  six  months 
to  a  year. 

While  the  description  given  above  applies  to  most 
cases  of  kala-azar,  variations  from  this  type  of  the  disease 
are  met  with.  In  some  instances  the  period  of  initial 
fever  seems  to  be  absent,  the  patient  gradually  becoming 
weak  and  ill  without  any  definite  symptoms  beyond  loss 
of  flesh  and  enlargement  of  the  liver  and  spleen.  In 
other  cases  the  onset  may  be  very  acute,  and  the  patient 
may  be  carried  off  by  fever  or  dysentery  before  the 
development  of  cachexia. 

For  so  serious  a  disease  the  symptoms  other  than  those 
mentioned  are  remarkably  slight.  Besides  headache,  those 
referable  to  the  nervous  system  are  chiefly  a  diminution  of 
nervous  energy  and  occasional  muscular  tremors,  resulting, 
for  example,  in  inability  to  write,  in  educated  patients. 

Cases  are  said  to  be  met  with  in  the  endemic  area  in 
which  the  symptoms  throughout  are  of  a  mild  nature. 


150  TROPICAL   MEDICINE   AND   HYGIENE 

The  symptoms  referable  to  the  circulatory  system  are 
chiefly  dependent  upon  anaemia.  In  the  early  stage  the 
pulse  is  less  rapid  than  might  be  anticipated  from  the 
height  of  fever  present,  while  later,  owing  to  the  anaemia, 
its  frequency  is  out  of  proportion  to  the  temperature,  and 
is  full,  though  very  soft.  Pulsation  of  the  carotids  is 
often  noticeable,  and  haemic  murmurs  are  common,  as 
also  is  palpitation  on  exertion. 

Anaemia  is  a  constant  symptom  of  kala-azar.  Its 
degree  varies  in  different  cases  and  at  different  periods 
of  the  disease,  but  is  usually  considerable,  though  not 
extreme.  It  commences  early  in  the  disease  and  there  is  a 
progressive  reduction  in  numbers  of  both  red  corpuscles 
and  leucocytes.  Instead  of  the  usual  5,000,000  red  cor- 
puscles to  the  cubic  millimetre,  only  half  that  number 
may  be  present,  though  3,000,000  or  3,500,000  are  more 
common  counts.  The  haemoglobin  value  of  the  red 
corpuscles  is  only  slightly  reduced.  The  diminution 
of  leucocytes  is  normal  or  more  marked  than  that  of 
the  red  corpuscles,  their  numbers  varying  from  3,000 
down  to  1,000,  or  even  to  only  500  to  the  cubic  milli- 
metre. This  marked  leucopenia  is,  according  to  Rogers, 
diagnostic  of  kala-azar. 

The  decrease  chiefly  affects  the  polymorphonuclear 
leucocytes,  while  the  mononuclear  elements  show  a 
considerable  relative  increase.  The  results  of  differential 
blood  counts  are  commonly  as  follows,  the  figures  given 
representing  percentages  :  polymorphonuclears,  40  to  60 ; 
lymphocytes,  20  to  30  ;  large  mononuclears,  13  to  16. 

Although  the  specific  parasite  may  be  met  with  in  the 
peripheral  blood,  it  occurs  so  sparingly,  especially  in 
the  early  stages  of  the  disease,  that  the  diagnosis  can 
rarely  be  made  by  blood  examination.  It  occurs  in 
the  polymorphonuclear  and  in  the  large  mononuclear 
leucocytes,  and  the  method  which  affords  the  best  chance 
of  finding  it  is  to  centrifugalize  2  or  3  c.c.  of  blood,  and 
after  separating  the  red  corpuscles  to  again  centrifugalize 
the    remainder    and    prepare    films    from    it.       Another 


KALA-AZAR  151 

method  is  to  in;ikc  blootl  lilins  Icnniiiatin^  in  a  thick 
edge  ;  leucocytes  accumulate  at  this  edge,  and  search  for 
the  organism  is  thus  faciHtated.  By  this  method  a  skilled 
observer  may  be  able  to  make  his  diagnosis  certain  by 
examination  of  the  peripheral  blood  alone.  Unless  the 
case  is  complicated  by  malaria,  no  malarial  parasites  or 
pigment  will  be  present  in  the  blood. 

Among  the  results  of  the  blood  changes  are  the  haemor- 
rhages from  mucous  surfaces  already  mentioned.  Of 
these  epistaxis  is  the  most  common  form,  and  is  some- 
times profuse  and  difficult  to  control;  in  other  cases 
slight  but  persistent  oozing  of  blood  from  the  nasal 
mucous  membrane  occurs  ;  bleeding  of  the  gums  is  not 
uncommon,  and  sometimes  intestinal  haemorrhages  occur, 
quite  apart  from  those  met  with  during  the  dysenteric 
attacks  of  the  final  stage.  Haematuria  is  occasionally- 
observed. 

Mention  may  here  be  made  of  the  occasional  presence 
of  slight  general  anasarca  ;  this  and  the  transitory  oedemas 
sometimes  met  with  are  probably  due  to  the  condition  of 
the  blood.  The  anasarca  may  be  most  marked  in  the 
face,  and  may  mask  the  emaciation. 

Digestive  System. — There  is  little  to  add  to  what  has 
already  been  said  of  symptoms  referable  to  the  digestive 
system.  During  the  early  stages  they  are  slight  or 
absent,  this  being  in  contrast  to  the  condition  usually 
met  with  in  malaria. 

While  diarrhoea  or  dysentery  are  usually  symptoms  of 
the  final  stage,  attacks  may  appear  at  any  period  of  the 
disease.  In  some  instances,  indeed,  soldiers  have  been 
invalided  from  India  to  England  for  dysentery,  and  the 
symptoms  of  kala-azar  have  supervened. 

The  enlargement  of  the  liver  and  spleen  is  usually  pain- 
less, though  these  organs  are  often  tender,  especially  in 
the  early  stage  of  the  disease.  Sometimes,  however,  there 
is  considerable  pain  in  the  liver,  which  has  led  to  the 
mistaken  diagnosis  of  hepatic  abscess.  While  the  enlarge- 
ment is  usually  progressive  until  towards  the  end,  variations 


152  TROPICAL   MEDICINE   AND   HYGIENE 

in  the  size  of  the  liver  and  spleen  sometimes  occur, 
diminution  being  usually  coincident  with  temporary- 
general  improvement  in  the  patient's  condition.  The 
slight  degree  of  ascites  not  infrequently  met  with  is 
probably  due,  at  least  partly,  to  the  obstruction  to  the 
circulation  caused  by  the  enlargement  of  the  liver  and 
spleen. 

The  urine  is  normal  in  most  cases  of  kala-azar,  though 
towards  the  end  it  may  contain  a  little  albumin.  Hasma- 
turia  is  a  rare  complication. 

Respiratory  System. — A  liability  to  congestion  of  the 
respiratory  passages,  as  evidenced  by  sore  throat  or  by 
slight  bronchitis,  is  common  in  patients  suffering  from 
kala-azar,  and  there  seems  to  be  a  special  liability  to 
pneumonia  during  the  later  stages  of  the  disease  ;  the 
pneumonia  is  of  the  ordinary  lobar  type.  True  tuber- 
cular phthisis  is  one  of  the  causes  of  death  in  kala- 
azar.  The  parasites  may  occur  in  the  lungs,  and  in  that 
case  nodules  resembling  tubercles  will  be  present. 

Cutaneous  System. — Darkening  or  pigmentation  of  the 
skin  is  sometimes  very  marked,  especially  among  dark- 
skinned  patients.  The  skin  of  Europeans  suffering  from 
this  disease  often  has  a  dull,  dirty  appearance.  Except 
for  occasional  petechias,  there  are  no  special  skin  erup- 
tions in  kala-azar. 

Cancrum  oris  is  frequently  met  with  in  the  last  stages  of 
kala-azar,  especially  in  children.  Although  nearly  always 
fatal,  cases  have  been  recorded  in  which  its  appearance 
has  been  followed  by  great  improvement  in  the  general 
symptoms  and  even  in  subsequent  recovery. 

Diagnosis.— With,  regard  to  the  diagnosis  of  kala-azar 
it  may  at  once  be  said  that  this  cannot  be  made  with 
certainty  except  by  the  demonstration  of  the  specific 
parasite.  In  Assam,  where  the  disease  was  first  recog- 
nized, medical  practitioners  who  have  been  familiar  with 
it  for  many  years  admit  that  in  the  early  stage  kala-azar 
cannot  be  readily  distinguished  clinically  from  malaria, 
and  that  even  in  the  later  stages  a  consideration  of  the 


KALA-AZAR  1 53 

history  of  the  patient  is  necessary  before  any  conchision 
can  be  arrived  at.  Should  the  patient  be  from  an  infected 
house  or  village,  and  should  the  development  of  his 
cachexia  have  been  more  rapid  than  is  usual  in  malaria, 
he  is  considered  to  be  suffering  from  kala-azar,  (otherwise 
the  diagnosis  of  his  disease  is  likely  to  be  malarial  cachexia. 
In  Madras,  too,  all  of  the  patients  in  whom  the  earliest 
discovery  of  the  parasite  had  been  made  during  life  had 
been  considered  to  be  suffering  from  malarial  cachexia, 
and  this  in  spite  of  the  fact  that  no  malarial  parasites 
could  be  discovered  by  repeated  examination  of  their 
blood.  Of  the  early  investigators  of  the  disease,  one 
beUeved  that  it  was  ankylostomiasis,  others  that  it  was 
a  special  epidemic  form  of  malaria,  while  yet  another 
believed  it  to  be  Malta  fever. 

An  important  feature  for  the  clinical  differentiation  of 
kala-azar  from  malaria  is  the  resistance  of  the  former 
disease  to  quinine,  and  should  this  resistance  be  definitely 
proved,  the  latter  may  be  excluded.  It  is  important  to 
note,  however,  that  the  two  diseases  may  co-exist,  and 
that  therefore  the  demonstration  of  malarial  parasites  in 
the  blood  and  their  disappearance  following  the  adminis- 
tration of  quinine  cannot  be  considered  as  definitely 
excluding  in  suspicious  cases  the  diagnosis  of  kala-azar. 
In  such  cases,  should  the  temperature  show  a  double  or 
triple  daily  curve,  and  should  there  be  little  or  no  diges- 
tive disturbance,  the  likelihood  of  their  being  kala-azar 
is  considerably  increased.  It  is  only  in  the  early  stages 
that  kala-azar  is  likely  to  be  mistaken  for  enteric  fever, 
from  which  the  points  just  mentioned  should  serve  to 
distinguish  it. 

The  examination  of  the  blood  is  an  essential  preliminary 
step  in  the  diagnosis  of  kala-azar.  The  combination  of 
marked  leucopenia  with  relative  increase  in  the  number 
of  mononuclear  leucocytes  at  once  differentiates  it  from 
a  number  of  diseases  which  at  some  stage  or  other 
resemble  it  in  some  respects,  but  in  which  this  condition 
is  absent.     Such  are  enteric  fever  and  Malta  fever  among 


154  TROPICAL   MEDICINE   AND   HYGIENE 

acute  and  splenic  anaemia  (Banti's  disease)  and  spleno- 
meduUary  leucocythemia  among  chronic  diseases,  in  all 
of  which  the  spleen  may  be  considerably  enlarged,  and 
a  varying  degree  of  anaemia  present,  but  in  which  the 
number  of  leucocytes  is  increased  —  in  the  chronic 
anaemias  very  greatly  so.  In  patients  suffering  from 
tropical  abscess  of  the  liver  there  is  usually  leucocytosis. 
This  may  not  be  marked  in  some  cases,  but  there  is  no 
leucopenia.  A  blood  count  would  differentiate  the  two 
diseases,  the  total  number  of  leucocytes  being  in  excess  in 
hepatic  abscess  and  diminished  in  kala-azar. 

The  diseases  other  than  kala-azar  in  which  leucopenia 
is  combined  with  a  relative  mononuclear  increase  are 
malaria  and  trypanosomasis.  In  malaria,  how^ever,  leuco- 
penia is  less  marked  than  in  kala-azar,  the  relative  pro- 
portion of  white  and  red  corpuscles  remaining  the  same 
as  in  normal  blood,  about  i  to  750.  In  kala-azar,  on  the 
contrary,  the  diminution  of  white  corpuscles  is  much 
greater  than  that  of  the  red,  the  proportion  falling  as  low 
as  I  to  1,500,  or  even  as  i  to  3,000. 

In  ankylostomiasis  there  is  leucocytosis  with  marked 
eosinophilia. 

Examination  of  the  blood  alone  should  not,  however, 
unless  the  specific  parasites  of  these  diseases  are  recog- 
nized, be  relied  upon  to  differentiate  them  from  kala-azar. 

To  place  the  diagnosis  beyond  doubt  the  demonstration 
of  the  parasite  of  kala-azar  is  necessary.  The  parasite  is 
most  readily  obtained  by  puncture  of  the  liver  or  spleen. 
The  risk  of  haemorrhage  following  puncture  of  the  spleen 
may  be  great  in  kala-azar  and  has  been  fatal.  It  is 
preferable  to  puncture  the  liver.  The  method  of  puncture 
is  as  follows  : — 

The  syringe  and  needle  must  be  sterilized  dry,  as  any 
admixture  with  water  may  cause  a  breaking  up  of  the 
parasite.  The  skin  over  the  site  selected  for  puncture 
must  be  thoroughly  sterilized  and  the  needle  plunged 
deep  into  the  liver  with  a  slight  rotatory  movement. 
When  well  in  the  liver  the  syringe  will  move  with  the 


KALA-AZAR  1 55 

respiratory  movements.  The  needle  should  be  kept  in 
position  for  about  a  minute  and  sh^iitly  \vith(h"a\vn  before 
gentle  aspiration  is  attempted.  Tiie  less  blood  that  is 
present  the  more  satisfaetory  is  the  operation,  as  the 
parasites  are  not  in  the  blood,  and  any  blood  present 
only  serves  to  dilute  the  fluid  and  render  it  more  difficult 
to  find  the  parasite. 

The  fluid  withdrawn  should  be  blown  out  on  to  a 
series  of  slides,  making  as  thin  films  as  possible.  These 
films  when  dry  may  be  stained  with  Leishman's  method, 
or  with  dilute,  i  in  4,  freshly  filtered  carbol-fuchsin  after 
fixation.  The  parasites  may  be  numerous  in  such  films, 
or  scanty,  and  several  films  should  be  examined  before  a 
negative  diagnosis  is  given.  They  can  be  recognized  by 
the  presence  of  two  chromatin  masses,  one  small,  rod-like 
and  deeply  staining,  the  other  larger,  oval,  and  staining 
less  deeply. 

Prognosis. — The  mortality  of  kala-azar  is  very  high. 
In  Assam  the  mortality  was  estimated  at  96  per  cent., 
but  it  is  most  likely  that  the  remaining  4  per  cent,  of 
the  patients  were  suffering  from  malarial  cachexia,  the 
difficulty  in  the  differentiation  of  which  from  kala-azar 
by  clinical  methods  alone  has  already  been  mentioned. 
In  Madras  the  case  mortality  is  recorded  as  98  per  cent. 
One  recovery  has  been  known  of  a  patient  invalided  to 
England  in  whom  the  diagnosis  was  fully  confirmed  by 
examination  by  liver  puncture,  and  in  whom  parasites 
were  also  found  in  leucocytes  in  the  peripheral  blood. 
Rogers,  however,  believes  that  a  fair  proportion  of  the 
cases  recover  if  properly  treated. 

PatJiological  AnaioJiiy. — The  most  noticeable  feature  in 
the  morbid  anatomy  of  kala-azar,  apart  from  the  great 
emaciation,  is  the  enlargement  of  the  spleen  and  liver. 
Besides  this,  inflammation  and  ulceration  of  the  large 
intestine,  and  some  degree  of  ascites  or  cedema  are 
common.  The  spleen  is  almost  invariably  very  greatly 
enlarged,  often  weighmg  over  80  oz.  ;  it  is  of  hrm  consis- 
tence, retaining  its  shape  on  removal.     There  is  usually 


156  TROPICAL   MEDICINE   AND   HYGIENE 

no  thickening  or  inflammation  of  the  capsule.  On  sec- 
tion the  surface  is  dark  red,  and  the  spleen  substance  is 
firm  and  friable;  should,  however,  the  examination  have 
been  delayed,  especially  in  warm  weather,  the  spleen 
substance  will  be  found  to  be  soft.  There  is  no  malarial 
pigmentation,  and  there  are  no  infarcts.  Microscopical 
examination  reveals  great  dilatation  and  enlargement  of 
the  splenic  capillaries,  with  reduction  in  the  lymphoid 
elements.  Scattered  irregularly  throughout  the  organ 
are  enormous  numbers  of  parasites,  the  Leishman  bodies. 
These  are  contained  chiefly  in  the  cells  lining  the  lymph 
spaces  and  in  the  endothelial  cells  of  the  capillaries. 
They  also  occur  in  the  spleen  cells  themselves,  and  in 
leucocytes,  chiefly  in  the  mononuclear,  but  also  in  some 
of  the  polymorphonuclear  cells.  They  are  not  met  with 
in  the  Malpighian  corpuscles  or  lymphatic  follicles. 

The  enlargement  of  the  liver  is  usually  less  propor- 
tionate than  that  of  the  spleen.  Like  the  spleen,  the 
liver  is  of  firm  consistence  and  friable.  It  is  usually  rather 
paler  than  normal  and  presents  a  nutmeg  appearance, 
this  being  due  partly  to  the  growth  of  mononuclear  cells, 
chiefly  in  the  centre  of  the  lobules,  and  partly  to  fatty 
degeneration  of  the  liver  cells.  Parasites  are  numerous 
in  the  endothelial  cells  of  the  capillaries  and  lymphatics, 
and  are  also  met  with  in  free  mononuclear  cells,  but  do 
not  occur  in  the  liver  cells  themselves.  Haemosiderin  is 
present  both  in  the  hepatic  cells  and  in  the  spleen  pulp. 

Next  to  the  spleen  and  liver  the  bone-marrow  is  the 
principal  seat  of  the  parasites,  which  occur  chiefly  in 
the  large  mononuclear  cells  ;  the  marrow  appears  to  be 
increased  in  amount  and  is  redder  than  normal. 

Should  death  have  been  brought  about  by  dysentery, 
as  is  so  commonly  the  case,  the  large  intestine  will  be 
found  thickened  and  inflamed,  the  descending  colon  and 
sigmoid  flexure  being  chiefly  affected.  The  inflammation 
sometimes  affects  the  whole  length  of  the  large  intestine, 
and  may  involve  the  lower  part  of  the  small  intestine. 
There  is  great  inflammatory  infiltration  of  all  the  coats 


KALA-AZAR  1 57 

of  the  bowel,  and  frequently  there  are  ulcers  extending 
from  the  mucous  to  the  serous  coat,  or  even  causing  per- 
foration ;  sometimes  the  mucous  membrane  is  covered 
with  a  tough  film  of  exudation. 

The  inflammation  of  the  intestine  does  not  appear  to 
be  directly  clue  to  the  Leishman  body,  for  but  few  of 
these  organisms  are  usually  found  in  its  coat;  they  occur 
chiefly  in  the  endothelial  cells  of  the  capillaries. 

In  uncomplicated  cases  the  other  organs  of  the  body 
appear  to  be  healthy,  but  even  in  this  case  parasites  may 
be  found,  though  sparingly,  in  the  endothelial  cells  of 
the  capillaries  and  lymph  spaces  of  various  organs,  e.g., 
lungs,  kidneys,  suprarenal  capsules,  and  lymphatic  glands. 
Sometimes  the  mesenteric  glands  are  enlarged,  and 
contain  the  specific  parasites  in  large  numbers.  In  spite 
of  the  wide  distribution  of  the  parasite  in  the  body  it 
has  never  been  found  in  any  of  the  secretions  or  excre- 
tions during  life.  The  difficulty  of  finding  the  organism 
in  the  blood  has  already  been  alluded  to. 

In  fresh  unstained  preparations  the  parasites  of  kala- 
azar  are  difficult  to  see.  They  appear  as  rather  retractile, 
motionless  bodies  of  indefinite  outline,  almost  colourless 
or  of  a  light  greenish  tinge,  and  may  be  mistaken  for 
blood  platelets. 

The  organisms  are  best  seen  when  stained  by  Roman- 
owsky's  method.  So  stained,  they  appear  as  sharply 
defined,  round  or  oval  bodies,  between  2  /j,  and  3  //.  in 
diameter,  of  a  faint  blue  colour,  and  containing  two 
masses  of  chromatin ;  one  large,  round,  of  a  light  violet 
colour,  the  other  small  and  rod-shaped,  and  staining  a 
deep  red,  almost  black.  The  two  chromatin  masses  are 
usually  situated  in  the  shorter  diameter  of  the  oval- 
shaped  parasites,  the  larger  at  one  pole,  the  rod  at  the 
other,  with  its  length  directed  at  the  larger  mass  across 
the  body  of  the  parasite.  The  rod  is  usually  sharph^ 
defined,  but  is  sometimes  reduced  to  a  mere  dot  of 
deeply  staining  chromatin.  The  organisms  are  remark- 
ably uniform  both  in  size  and  appearance  ;  they  appear 


158  TROPICAL  MEDICINE   AND   HYGIENE 

to  possess  a  strong  cell  wall  which  resists  distortion,  and 
the  relative  size  and  position  of  the  chromatin  masses 
are  very  constant.  The  cytoplasm  of  the  parasite  shows 
little  or  no  structure,  but  sometimes  vacuoles  are  seen 
in  it.  Besides,  by  Romanowsky's  method,  the  parasites 
can  be  stained  by  many  of  the  basic  aniline  dyes,  weak 
carbol-fuchsin  and  carbol-thionine  perhaps  giving  the 
best  results. 


Fig.  38. 

In  smears  obtained  from  the  liver  and  spleen  during 
life  the  parasites  may  either  be  free  or  contained  in  cells 
or  embedded  in  a  matrix.  The  matrix  is  not  seen  in 
smears  made  from  organs  after  death,  nor  in  sections 
in  which  the  parasites  always  appear  to  be  intracellular. 
In  the  great  majority  of  cases  the  cells  containing  the 
parasites  appear  to  be  endothelial  cells  of  capillaries  and 
lymph  spaces,  either  unaltered  or  of  large  size  and 
irregular  shape,  constituting  macrophages.  The  macro- 
phages often  contain  large  numbers  of  parasites,  upon 
which  they  appear  to  exert  no  phagocytic  action.  On 
the  contrary,  under  the  influence  of  the  parasites  the 
macrophages  undergo  gradual  disintegration,  and  in  all 


KALA-AZAK  1 59 

probability  furnish  the  matrix  seen  in  antc-uiorletii 
smears. 

Next  to  the  endothelial  cells  the  large  mononuclear 
leucocytes  most  frequently  harbour  the  parasites,  and 
a  few  are  found  in  the  polymorphonuclear  leucocytes; 
they  also  occur  in  the  myelocytes  of  bone-marrow,  but 
are  not  met  with  in  parenchymatous  cells. 

When  obtained  post  morteni,  and  especially  if  several 
hours  have  elapsed  since  the  death  of  the  patient,  many 
of  the  parasites  show  changes  indicative  of  development. 
They  are  larger,  3  /a  to  5  yu-  in  diameter,  the  chromatin 
masses  show  signs  of  division  and  may  even  be  re- 
duplicated, and  commencing  cleavage  of  the  cytoplasm 
is  seen,  each  half  containing  a  large  and  a  small  chromatin 
mass. 

In  sections,  owing  to  shrinkage,  the  parasites  appear 
much  smaller  than  in  smears  ;  the  chromatin  masses  are 
closer  to  each  other  and  the  smaller  has  frequently  lost 
its  rod-shaped  appearance. 

Etiology. — The  etiology  of  kala-azar  is  of  special  in- 
terest, both  because  of  the  repeated  failures  which  have 
attended  the  investigations  undertaken  for  its  elucida- 
tion, and  because  of  the  remarkable  series  of  observations 
which  have  resulted  in  the  discovery  of  the  cause  of  the 
disease  and  the  nature  of  the  specific  parasite,  and 
probably   of   its  mode  of  transmission  and  prophylaxis. 

The  great  mortality  caused  by  epidemics  of  kala-azar 
in  Assam,  during  the  last  two  decades  of  the  nineteenth 
century,  prompted  the  Government  of  India  to  send 
one  medical  officer  after  another  to  investigate  the 
disease,  and  if  possible  to  discover  its  cause  and  devise 
methods  for  its  prevention.  All  the  investigations  so 
undertaken,  although  carried  out  with  great  care,  failed 
in  their  object.  One  observer,  influenced  by  the  ana2mia 
of  the  patients  and  by  the  discovery  that  man}-  of  them 
harboured  ankylostomes,  considered  that  the  disease 
was  essentially  ankylostomiasis.  Another  came  to  the 
conclusion  that  kala-azar  was  malarial  fever,  which  had 


l6o  TROPICAL   MEDICINE   AND    HYGIENE 

acquired  an  intense  and  communicable  form;  and  a 
third  investigator,  while  noticing  the  absence  of  malarial 
parasites  in  the  blood  and  of  melanin  pigment,  thought 
that  it  was  a  form  of  malaria  with  marked  incidence 
on  the  liver  and  spleen,  and  with  a  mortality  enhanced 
by  the  concurrence  of  ankylostomiasis  or  of  dysentery. 
The  subject  stood  thus  when,  in  May,  1903,  Leishman 
published  in  the  British  Medical  Journal  a  short  note 
entitled  "  On  the  Possibility  of  the  Occurrence  of 
Trypanosomiasis  in  India."  A  few  years  previously,  in 
1900,  he  had  noticed  in  smears  made  from  the  spleen 
of  a  soldier,  who  had  died  at  Netley  of  tropical  cachexia 
and  dysentery,  contracted  near  Calcutta,  enormous 
numbers  of  the  small,  round,  oval  bodies,  with  the  two 
characteristic  chromatin  masses  already  described.  As 
to  the  meaning  of  these  bodies  Leishman  was  at  a  loss. 
In  1903,  however,  he  found  almost  exactly  similar  bodies 
in  the  spleen  of  a  white  rat,  which  forty-eight  hours 
previously  had  died  of  infection  with  the  trypanosome 
of  Nagana.  Up  to  the  time  of  its  death  the  blood  of 
this  rat  was  swarming  with  trypanosomes,  and  experi- 
ments proved  that  it  was  possible  to  trace  every  step 
in  the  degenerative  changes  which  lead  to  the  formation 
of  the  small  rounded  bodies,  the  two  chromatin  masses 
of  which  represented  without  doubt  the  macro-  and 
micro-nuclei  of  the  trypanosomes  from  which  they  had 
been  formed  (fig.  39).  This  second  observation  gave  a 
clue  to  the  explanation  of  the  first,  and  Leishman  felt 
himself  justified  in  suggesting  not  only  that  the  soldier 
had  suffered  from  trypanosomiasis,  but  that  "  some  of 
these  severe  tropical  cachexias,  such  as  Dum-dum  fever, 
as  well  as  kala-azar  and  sleeping  sickness,  might  be  due 
to  trypanosomiasis.  These  suggestions  have  been  justi- 
fied to  the  extent  that  the  parasites  have  been  proved  to 
develop  flagella. 

In  July,  1903,  Donovan  announced  that  some  months 
previously  he  had  seen  the  bodies  described  by  Leishman 
in  the  spleens  of  several  patients,  who  had  died  at  Madras 


KALA-AZAR 


l6l 


of  what  was  considered  to  be  chronic  maluria,  but  lie  was 
not  aware  of  their  nature  until  he  had  seen  Leishman's 
paper,  and  that  he  had  since  found  identical  bodies  in 
the  blood,  obtained  by  puncture,  of  the  spleen  durinjf 
the  life  of  a  patient  suffering  from  irregular  pyrexia, 
and  in  whose  blood  no  malarial  parasites  could  be  found. 
In  the  following  January,  Bentley  discovered  similar 
bodies  in  spleen  smears  from  living  patients  suffering 
from  kala-azar  in  Assam,  and  since  then  numerous 
similar  observations  have  been  made  as  regards  cases 
presenting  similar  symptoms,  where  the  disease  was  con- 
tracted in  or  near  Calcutta,  and  in  certain  other  places 
in  India  and  elsewhere.  It  may,  however,  be  noted  here 
that   the   parasite   has   not   been    discovered    in   patients 


Fig.  39, — a,  Trypanosomes  and  the  altered  forms  found  in  culture  ;    b,  Leish- 
man-Donovan  bodies  and  the  altered  forms  found  in  culture. 


suffering  from  "  malarial  cachexia  and  enlarged  spleen  " 
in  the  Punjab  where  organisms  morphologically  similar 
have  been  shown  to  occur  in  Delhi  boils. 

A  further  stage  in  the  etiology  of  the  disease  was 
reached  in  November,  1904,  when  Rogers  announced 
that  he  had  observed  the  development  from  the  parasite 
of  flagella,  leaving,  as  he  said,  "  but  little  room  for  doubt 
that  the  human  parasite  belongs  to  the  flagellates." 
Rogers's  observations  have  been  confirmed  by  others, 
including  Leishman  (fig.  39). 

The  flagellate  organism  into  which  the  Leishman 
II 


l62  TROPICAL   MEDICINE   AND   HYGIENE 

body  develops  differs  from  a  true  trypanosome  in  that 
it  does  not  possess  an  undulating  membrane,  and  that  its 
flagellum  and  micro-nucleus  are  situated  at  the  blunter, 
posterior  end  of  the  parasite.  It  thus  resembles  a  her- 
petomonas.  Similar  forms  have,  however,  been  observed 
in  the  so-called  cultivations  of  true  trypanosome,  and 
Rogers  noticed  forms  in  his  cultures  similar  to  those 
described  by  Bradford  and  Plimmer  as  occurring  in  the 
lungs  of  animals  artificially  infected  with  Trypanosoma 
brucei. 

Mention  may  be  made  of  the  opinion  expressed  by 
Laveran  and  Mesnil  that  the  Leishman  body  is  a  piro 
plasma,  and  of  Ross's  suggestion  that  it  belongs  to  a  new 
genus  which  he  named  Leishmania,  calling  the  parasite 
Leishmania  donovani.  Both  these  opinions,  however, 
were  expressed  before  the  development  into  flagellaie 
forms  had  been  observed.  Rogers  found  that  when  the 
blood  obtained  by  spleen  puncture  of  patients  suffering 
from  kala-azar  was  mixed  with  sterile  sodium  citrate 
solution,  and  kept  at  a  temperature  of  22°  C.  for  a  few 
ciays,  developmental  forms  occurred.  The  cytoplasm  of 
the  parasites  increased  in  size,  became  granular,  and  the 
body  became  elongated,  the  macronucleus  enlarged  and 
the  micronucleus  migrated  to  the  thicker  end  of  the 
organism  from  which  a  flagellum  arose.  The  protrusion 
of  the  flagellum  was  preceded  by  the  formation  in  the 
cytoplasm  surrounding  the  micronucleus  of  a  rounded 
mass  which  stained  with  eosin,  the  rest  of  the  cytoplasm 
staining  blue  with  Leish man's  stain. 

In  one  instance,  long,  flagellate  forms  were  developed 
within  twenty-four  hours,  these  chiefly  occurring  in 
pairs.  In  later  experiments  (1905)  Rogers  has  found 
that  the  development  of  flagellated  forms  from  kala-azar 
parasites  takes  place  more  freely  and  with  greater  regu- 
larity in  an  acid  than  an  alkaline  medium,  and  that 
sterility  of  the  medium  is  e'ssential.  This  has  led  him 
to  suggest  that  the  intermediate  host  of  the  parasite 
might  be  the  bed-bug,  the  intestinal  contents  of   which 


KALA-AZAK  163 

he  found  supplied  these  conditions.  Working  on  this 
hypothesis,  Patton  has  announced  that  he  has  been  able 
to  trace  the  complete  cycle  of  the  parasites  up  to  com- 
pletely developed  flagellates  in  certain  tropical  bed-bugs, 
and  that  in  his  opinion  there  is  no  doubt  that  the  Indian 
bed-bug,  Cimex  rotundatus,  transmits  the  disease. 

The  rarity  of  the  occurrence  of  the  parasites  in  the 
peripheral  blood  has  been  advanced  as  an  argument 
against  this  method  of  infection.  Donovan  has,  how- 
ever, shown  that  they  occur  in  the  peripheral  blood  in 
the  leucocytes  intermittently  in  all  cases  of  kala-azar,  and 
at  times  may  be  fairly  numerous.  It  must  also  be  re- 
membered that  trypanosomiasis  can  often  be  transmitted 
by  the  injection  of  blood,  the  microscopical  examination 
of  which  fails  to  reveal  any  parasites. 

In  the  Assam  epidemics  kala-azar  spread  slowly  from 
village  to  village  along  the  lines  of  communication. 
Isolated  villages,  or  those  to  which  persons  from  outside 
were  not  admitted,  remained  free  from  attack,  and  the 
common  history  of  infected  villages  was  that  some  person 
had  arrived  there  suffering  from  the  disease  ;  after  a  short 
time  the  members  of  his  household  were  attacked  and 
the  disease  gradually  spread  from  house  to  house.  Rogers 
reports  that  he  has  observed  a  similar  house  or  family 
incidence  among  his  hospital  cases  of  kala-azar  at  Cal- 
cutta. 

All  these  facts,  as  well  as  the  success  which  has  attended 
attempts  to  stamp  out  epidemics  of  kala-azar  in  Assam 
by  the  isolation  of  patients,  coupled  with  the  burning  of 
infected  huts,  is  in  favour  of  the  view  that  the  disease 
is  transmitted  by  some  house-infesting  parasite,  such  as 
a  bug. 

A  suggestion  based  upon  the  consideration  of  the  low^ 
temperature  at  which  the  flagellate  forms  are  developed 
ill  vifiv  from  the  oval  forms  obtained  from  the  spleen,  is 
that  the  parasites  escape  in  the  faeces  and  undergo  a  stage 
of  development  in  some  cold-blooded  animal,  a  ilsh  or 
mollusc,  and  that  they  obtain  entrance  into  the  human 


±64  TROPICAL   MEDICINE   AND   HYGIENE 

body  by  the  ingestion  of  such  alternative  hosts,  either 
direct  or  through  the  water  supply.  There  is,  however, 
no  experimental  evidence  in  support  of  this  suggestion, 
and  the  circumstances  that  the  parasites  cannot  be  found 
in  the  faeces,  and  that  a  sterile  medium  is  required  for 
the  development  of  flagellate  forms,  are  opposed  to  it. 

The  seasonal  prevalence  of  kala-azar,  as  shown  by  the 
number  of  fresh  attacks,  is  greatest  in  the  cold  weather 
months,  November  to  April,  in  Assam  and  Lower  Bengal. 
The  "cold  weather"  temperature  in  this  area  ranges 
between  60°  and  75°  F.,  and  Rogers  points  out  that  it  is 
only  within  these  limits  that  developmental  forms  of  the 
parasite  are  obtainable  in  vitro.  He  suggests  that 
epidemics  of  kala-azar  have  been  due  to  a  succession  of 
periods  of  prolonged  cold  weathers,  which  have  extended 
the  conditions  favourable  to  the  extra-corporeal  develop- 
ment of  the  parasite.  He  further  suggests  that  the  more 
severe  cold  weather  of  North-west  India  accounts  for 
the  absence  of  kala-azar  there. 

As  has  been  seen,  kala-azar  when  epidemic  may  carry 
off  entire  households,  persons  of  either  sex  and  all  ages 
being  liable  to  attack.  Rogers  states  that  males  and 
females  are  attacked  in  equal  proportion,  and  that  infants 
and  old  people  are  less  liable  than  others  to  the  disease, 
while  it  is  commonest  among  children  and  young 
adults. 

As  to  race,  kala-azar  is  comparatively  rare  among 
Europeans  in  India  and  occurs  chiefly  among  the  poor 
whose  domestic  hygiene  in  places  like  Calcutta  resembles 
that  of  natives.  In  Assam  it  has  been  noticed  that  in- 
fection of  Europeans  is  often  traceable  to  cohabitation 
with  natives,  or  to  occur  in  missionaries  and  others  whose 
duties  bring  them  into  close  contact  with  natives.  Rogers 
has  pointed  out  that,  in  contrast  to  the  case  of  enteric 
fever,  kala-azar  occurs  more  commonly  among  Euro- 
peans who  have  lived  some  years  in  India  than  in 
newcomers. 

Treatment. — Once  kala-azar  has  become  well  developed,. 


KALA-AZAR  1 65 

no  treatment  seems  to  liave  any  effect  upon  the  course 
of  the  disease.  It  is  claimed  by  some  that  quinine  in 
very  large  doses  may  arrest  the  disease  at  a  very  early 
stage,  but  it  is  possible  that  cases  responding  to  quinine 
are  malarial.  Besides  quinine  a  very  great  number  oi 
drugs  have  been  tried — arsenic,  the  salicylates,  and  also 
bone-marrow  —  but  with  little  effect.  More  recently 
atoxyl  has  been  given,  but  the  results  are  not  rapid,  though 
in  one  case  so  treated  recovery  has  taken  place.  It  is 
possible  that  careful  attention  to  the  general  health  of 
the  patient,  coupled,  in  the  case  of  Europeans,  with 
residence  in  a  temperate  climate,  may  prolong  life  a  little, 
and  it  is  important  that  such  measures  should  not  be 
neglected,  for  they  at  any  rate  add  greatly  to  the  patient's 
comfort,  and  throughout  the  disease  treatment  must  be 
symptomatic. 

The  marked  improvement  in  the  condition  of  kala-azar 
patients  who  have  recovered  from  an  intercurrent  attack 
of  some  inflammatory  affection  suggests  the  trial  of 
measures  for  inducing  leucocytosis. 

The  diet  should  be  liberal,  but  it  is  important  to  avoid 
overfeeding  and  foods  difficult  of  digestion,  for,  as  has 
been  seen,  the  voracious  appetite  of  kala-azar  patients,  if 
unchecked,  frequently  results  in  digestive  troubles. 

Prevention. — In  view  of  the  part  played  in  all  prob- 
ability by  the  Eastern  bed-bug,  Ciinex  rotimdatiis,  in 
the  transmission  of  kala-azar,  cleanliness,  domestic  and 
personal,  is  the  best  safeguard  against  the  disease.  In 
countries  where  the  disease  prevails  every  effort  should 
be  made  to  rid  houses  of  these  parasites.  Old  bug- 
infested  houses  should  be  abandoned  and  burnt,  as  it  is 
very  difficult,  if  not  impossible,  to  free  such  houses  from 
bugs  by  milder  measures.  In  other  circumstances,  should 
the  disease  appear,  the  patients  should  be  isolated,  the 
infected  houses  thoroughly  fumigated  with  sulphur  or 
pyrethrum,  all  beds  and  furniture  likely  to  harbour  bugs 
soaked  in  boiling  carbolic  solution  or  similar  disinfectant, 
and    all     clothes     and    bedding     similarly     disinfected. 


l66  TROPICAL   MEDICINE   AND   HYGIENE 

Segregation  of  patients  and  the  burning  of  infected  huts 
have  proved  successful  for  dealing  with  outbreaks  of 
kala-azar  in  Assam. 

Varieties. — The  specimens  of  the  parasites  obtained  by 
Durling  in  Panama  present  certain  differences,  in  that  the 
parasites  are  larger  and  the  ectoplasm  more  definite  and 
thicker.  In  this  form  the  lungs  are  more  frequently 
attacked.     It  may  be  a  different  species. 


1 67 


CHAPTER  XIII. 
ORIENTAL   SORE. 

Aleppo  Evil,  Aurangzebe,  Bouton  de  Baghdad, 
Clou  de  Biskra,  Date  Sore,  Delhi  Boil,  Fron- 
tier Sore,  Orient  Buele,  Yemen  Ulcer. 

The  various  names  mentioned  above,  and  many  others, 
are  given  to  ulcers  occurring  in  Algeria,  Egypt,  Asia 
Minor,  the  Levant,  Cyprus,  Arabia,  Persia,  Northern 
India,  and  other  subtropical  countries,  and  characterized 
by  the  thick  crusts  which  form  on  their  surface,  and  by 
their  great  chronicity. 

The  affection  begins  as  a  small  red,  itching  papule, 
resembling  the  effect  of  a  mosquito  bite.  This  soon 
increases  in  size,  becomes  shiny  and  transparent,  and 
surrounded  by  a  red  areola.  Later  there  is  a  serous 
discharge  which,  together  with  desquamated  epithelial 
scales,  form  a  crust  which  is  often  studded  with  small 
yellow  points.  Underneath  the  crust  ulceration  takes 
place,  until  the  crust  giving  way,  an  indolent  ulcer  is 
exposed,  which  slowly  spreads.  The  surface  of  the  ulcer 
is  studded  with  flabby  red  granulations,  which  bleed 
readily  on  pressure ;  its  base  is  freely  movable  over  the 
subjacent  tissues,  and  its  edges'  are  raised,  irregular  and 
slightly  indurated.  There  is  always  a  considerable 
amount  of  thin,  serous  or  purulent  discharge  which 
coagulates,  forming  dirty  yellow  crusts.  The  degree  of 
pain  varies ;  often  there  is  little  or  none,  but  sometimes, 
especially  if  irritated,  or  if  the  discharge  be  pent  up  by 
thick  scabs,  the  ulcer  is  very  painful  and  the  edges  acutely 
tender. 


l68  TROPICAL   MEDICINE   AND   HYGIENE 

The  ulcer  slowly  spreads  in  an  irregular  manner  for 
some  time,  often  for  several  months,  and  either  of  itself 
or  by  coalescing  with  similar  ulcers  forms  a  large  open 
sore  an  inch  or  two  in  diameter.  After  a  time  the  ulcer 
ceases  to  spread  and  slowdy  heals,  the  healing  process 
being  often  interrupted  by  the  retention  of  the  discharge 
beneath  the  crusts.  Depressed,  pitted,  and  pigmented  but 
superficial  scars  are  left  which  may  be  mistaken  for 
those  of  syphilis.  These  ulcers  are  most  common  on 
exposed  parts  of  the  body,  especially  on  the  face,  neck, 
wrists,  and  on  the  back  of  the  hands  and  dorsum  of  the 
feet.  They  may  be  single,  but  are  more  commonly 
multiple,  and  are  irregularly  distributed.  There  is  usually 
no  enlargement  of  the  lymphatic  glands.  As  a  rule, 
there  is  no  constitutional  disturbance,  but  if  numerous 
and  severe  the  ulcers  lead  to  gradual  impairment  of  the 
health. 

Pathological  An  atomy. — Oriental  sore  is  essentially  an 
infective  granuloma.  The  proper  elements  of  the  skin 
and  its  accessories,  the  hair  and  sebaceous  follicles,  and 
the  sweat  glands  are  invaded  and  destroyed  by  granulation 
tissue,  which  extends  deeply  into  the  corium  and  necroses 
superfically,  thus  producing  an  ulcer.  In  the  early  stage, 
before  an  ulcer  is  formed,  there  is  proliferation  of  the 
cuticular  cells  leading  to  the  formation  of  papules ;  later 
this  proliferation  extends  a  little  in  advance  of  the  edges 
of  the  ulcer.  The  cells  composing  the  granulation  tissue 
are  almost  exclusively  of  the  mononuclear  type.  They 
are  large  rounded  cells  with  prominent  nuclei,  and  are 
apparently  of  endothelial  origin.  The  appearance  is  thus 
very  different  from  that  of  simple  ulceration  of  the  skin, 
in  which  polymorphonuclear  cells  predominate.  A  few 
of  these  cells  also  occur  in  Oriental  sore,  but  giant  cells, 
such  as  those  seen  in  tubercular  and  some  syphilitic 
affections  of  the  skin,  are  not  met  with. 

Scattered  throughout  the  granulation  tissue,  but  chiefly 
contained  in  the  large  mononuclear  cells,  are  vast  numbers 
of  parasitic  organisms,  very  similar  to  those  occurring  in 


OKIKNTAL   SOKK  I  69 

kala-azar,  Tlicsc  bodies  were  lirsl  described  as  occurring 
in  Oriental  sore  by  Wright,  of  Boston,  in  1903.  He 
discovered  them  in  an  ulcer  contracted  in  Armenia  some 
months  previously.  The  discovery  was  confirmed  as 
regards  similar  sores  contracted  at  Delhi,  Lahore,  Quetta 
and  other  places  in  Northern  and  Western  India  by  James 
in  1904,  and  as  regards  Egypt  by  Billot.  'l"he  parasites 
are  indistinguishable  morphologically  from  those  of  kala- 
azar,  a  description  of  which  will  be  found  on  p.  157. 
James  described  the  occurrence  in  some  of  the  parasites 
of  a  third  chromatin  mass — a  rod  tapering  towards  the 
micronucleus  and  at-  right  angles  to  it.  He  believed  it 
not  to  occur  in  the  organism  of  kala-azar,  but  it  has  since 
been  shown  to  do  so. 

Etiologv. — From  the  great  abundance  throughout  the 
cells  composing  the  granulation  tissue  of  Oriental  sore 
of  the  binucleated  organisms  described  by  Wright  and 
James,  it  seems  highly  probable  that  these  are  the  cause 
of  the  disease.  How  they  enter  the  body  is  unknown, 
but  long  before  their  discovery  the  malady  was  considered 
to  be  of  a  parasitic  nature,  and  various  parasitic  bodies 
were  described  as  occurring  in  the  affected  tissues. 
Among  these  mention  should  be  made  of  the  bodies 
described  in  1885  by  Cunningham,  and  considered  by 
him  to  be  monadina.  From  his  description  and  figures 
there  can  be  little  doubt  that  the  bodies  he  considered  to 
be  parasites  were  the  large  endothelial  cells  containing  the 
organisms  described  by  Wright  and  James,  the  magnifica- 
tion and  staining  methods  at  his  command  not  admitting 
of  more  precise  differentiation.  It  may  be  added  that 
Cunningham's  description  of  the  histological  appearances 
of  the  sores  is  in  close  agreement  with  those  of  Wright 
and  James. 

While  many  of  the  earlier  observers  agreed  that  water 
was  in  some  way  responsible  for  these  sores,  some  attri- 
buted them  to  its  chemical  contents,  and  others  to  its  con- 
taining parasites  which  were  ingested  or  entered  through 
abrasions  in  the  skin.     Other  suppositions  are  that  these 


170  TROPICAL   MEDICINE   AND    HYGIENE 

sores  are  the  result  of  bites  of  mosquitoes  or  of  sandflies 
or  other  biting  flies,  or  that  the  parasites  exist  in  the  soil 
and  are  directly  inoculated  by  accidental  abrasions.  It  is 
least  possible  that  infection  may  be  carried  directly  from 
an  Oriental  sore  to  simple  ulcers  or  wounds  by  flies  so 
common  in  places  where  the  disease  is  prevalent.  The 
circumstance  that  these  sores  are  most  common  on  parts 
of  the  body  not  protected  by  clothes,  and  especially  on 
the  face  and  neck  which  are  not  particularly  liable  to 
abrasions,  is  in  favour  of  the  view  that  the  parasite  is 
introduced  by  some  biting  insect,  the  nature  of  the 
organism  favouring  this  view. 

It  has  been  suggested  that  true  Oriental  sore  only 
occurs  in  countries  in  which  camels  are  in  common  use, 
and  that  infection  is  in  some  way  derived  from  camels. 
The  disease,  however,  is  more  prevalent  among  town- 
dwellers  than  among  those  who  have  especially  to  do 
with  camels  or  who  usually  lead  a  nomadic  life. 

It  has  been  shown  that  Oriental  sore  can  be  directly 
inoculated  in  man  and  there  is  a  strong  popular  belief 
that  recovery  is  followed  by  immunity,  so  much  so  that 
in  certain  places  it  is  the  practice  to  inoculate  children 
on  unexposed  parts  of  their  bodies  with  matter  taken 
from  such  sores,  with  the  object  of  avoiding  disfigure- 
ment of  the  face.  Attempts  have  been  made  to  inoculate 
dogs  and  other  animals  with  pus  from  Oriental  sore,  but 
without  success.  Sores  occurring  in  dogs  at  Delhi,  and 
locally  believed  to  be  of  the  same  nature  as  Delhi  boils 
in  man,  were  shown  by  James  to  contain  numerous 
spirilla,  but  no  Leishman  bodies. 

In  places  where  Oriental  sore  is  very  prevalent,  children 
are  the  principal  sufferers,  and  newcomers  are  specially 
liable  to  attack.  Where  less  common,  persons  between 
15  and  30  are  most  affected.  Otherwise,  age,  sex  and  race 
appear  to  be  without  influence.  The  seasonal  prevalence 
varies  in  different  places,  but  the  attacks  appear  to  be 
most  common  at  the  beginning  and  end  of  the  hot 
weather. 


ORIENTAL   SORK  17I 

Diagnosis. — Tlie  description  given  above  should  be  a 
sufficient  guide  to  the  nature  of  the  affection,  and  the 
diagnosis  can  be  established  by  the  discovery  of  the 
specific  parasite.  Syphilis  is  the  disease  for  which  Oriental 
sore  is  most  likely  to  be  mistaken.  The  absence  of  the 
other  symptoms  of  syphilis  and  the  failure  of  anti- 
syphilitic  treatmeht  should  enable  a  correct  diagnosis  to 
be  made. 

The  treatment  of  Oriental  sore,  unless  thoroughly 
carried  out,  is  very  unsatisfactory.  Internal  medication 
has  no  effect.  If  protected  from  irritation  they  heal 
very  slowly,  but  with  slight  scarring.  Of  local  applica- 
tions, copper  sulphate  solution  i  to  4  per  cent,  gives 
perhaps  the  best  results.  If  the  diseased  tissues  are  com- 
pletely destroyed  healing  is  more  rapid  but  the  scar  may 
be  greater.  In  the  early  stage  complete  excision  may  be 
possible,  but  failing  this,  the  surface  and  edges  of  the 
ulcer  should  be  thoroughly  scraped  and  ordinary  anti- 
septic dressings  applied.  Should  scraping  be  considered 
inadvisable  some  caustic  application,  preferably  strong 
carbolic  acid,  may  be  applied.  Others  use  caustic  alkalies, 
such  as  potassa  fusa.  Change  of  air  is  often  of  great 
benefit  in  obstinate  cases. 

Prevention. — In  the  present  state  of  knowledge  concern- 
ing the  manner  in  which  Oriental  sore  is  contracted  it  is  not 
possible  to  give  precise  directions  for  its  avoidance.  The 
proved  inoculability  of  the  ulcers  suggests  the  import- 
ance of  measures  to  avoid  direct  contagion,  these  includ- 
ing, besides  personal  cleanliness,  the  covering  of  the  sores 
with  some  antiseptic  application.  Until  it  has  been  shown 
that  the  water  of  places  in  which  the  disease  prevails  is 
innocuous,  it  would  be  well  to  boil  it  before  use,  either  for 
drinking"  or  washing.  Similarly  the  bites  of  insects  and 
contamination  by  flies  are  to  be  avoided. 


172 


CHAPTER  XIV. 
RELAPSING  FEVER. 

Famine  Fever  ;  Spirillum  Fever  ;  French,  Fievre 
A  Rechutes  ;  German,  Ruckfallsfieber. 

An  acute  infective  fever  characterized  by  the  presence 
of  spirilla  in  the  blood  and  by  the  common  occurrence 
of  relapses.  Relapsing  fever  was  formerly  common  in 
the  British  Isles,  especially  in  Ireland,  where  the  associa- 
tion of  its  attacks  with  famine  gave  it  the  name  of 
"  famine  fever."  Epidemics,  also  associated  with  scarcity, 
have  occurred  in  several  countries  of  Northern  Europe, 
most  commonly  in  Russia,  where  there  have  been  recent 
outbreaks.  There  was  also  an  outbreak  in  Austria  in 
1Q03.  In  its  epidemic  form  the  disease  is  now  most 
common  in  India,  more  particularly  in  the  Bombay 
Presidency.  Outbreaks  have  also  occurred  in  recent 
years  in  Northern  China  and  in  Egypt,  and  cases  have 
been  met  with  in  various  parts  of  the  world,  including 
Mexico,  New  York,  Cuba,  London,  Northern  Africa,  the 
Sudan,  Palestine,  Hong  Kong,  and  the  Philippines. 

The  disease  is  probably  much  more  common  than  is 
supposed,  for  without  systematic  examination  of  the  blood 
isolated  cases  are  almost  certain  to  escape  recognition. 
With  such  examination  it  would  probably  be  recognized 
at  any  large  seaport  among  the  crews  of  vessels  arriving 
from  the  Tropics. 

Incubation. — The  most  common  duration  of  the  incuba- 
tion period  of  relapsing  fever  is  two  to  five  days.  The 
extremes  which  have  been  noted  are  twelve  hours  and 
eight  days. 


KliLAPSKNG    KEVKK  I73 

The  course  of  an  attack  of  relapsiniL^  fever  is  commonly 
as  follows  : — 

Clinical  Course. — After  a  few  hours  of  malaise  the  patient 
is  suddenly  seized  with  chills,  and  in  two  or  three  hours 
he  is  sulTermg  from  higli  fever,  with  a  hot,  dry  skin,  with 
rapid  pulse,  severe  frontal  headache,  and  great  pain  in  the 
back  and  limbs.  Bilious  vomiting  sets  in,  acc(jmpanied 
by  much  thirst  and  by  pain  and  tenderness  of  the  upper 
part  of  the  abdomen.  Considerable  prostration  ensues, 
and  by  the  second  day  of  his  illness,  if  not  earlier,  the 
patient  takes  to  his  bed.  Here  he  lies  for  about  a  week, 
his  tongue  becomes  dry  and  coated,  his  bowels  consti- 
pated, and  his  liver  and  spleen  enlarged  and  tender. 
Jaundice  may  supervene,  and  slight  bronchitis  is  common 
at  this  stage. 

The  patient  is  troubled  with  sleeplessness  (the 
insomnia  resembling  that  of  a  patient  with  delirium 
tremens),  or  he  may  be  delirious.  His  aspect  is  weary,  his 
face  livid,  and  his  condition  appears  to  be  very  serious. 
On  or  about  the  seventh  day,  however,  a  crisis  occurs. 
Following  a  brief  increase  in  the  severity  of  the  symptoms, 
copious  perspiration  sets  in,  the  temperature  falls  very 
rapidly,  and  symptoms  of  collapse  may  follow,  not  infre- 
quently accompanied  by  diarrhoea  or  even  dysentery. 
In  a  favourable  case,  however,  the  collapse  is  not  serious, 
the  patient  falls  asleep  and  wakes  after  a  few  hours, 
apparently  convalescent.  After  about  a  week  of  this 
seeming  convalescence  the  patient  is  subjected  to  another 
attack  of  fever  commencing  almost  as  suddenly  as  the 
first. 

The  symptoms  of  the  relapse  are  similar  to  those  of 
the  initial  attack,  but  milder,  though  the  fever  may  be 
higher  and  the  debility  more  pronounced.  The  duration 
is,  however,  shorter.  A  second  crisis  occurs  on  or  about 
the  fifth  day,  and  is  usually  followed,  after  a  short  con- 
valescence, by  complete  recovery.  Sometimes,  however, 
a  second,  and  in  decreasing  frequency  a  third,  fourth,  or 
fifth  relapse  may  occur.  On  the  other  hand,  there  may 
be  no  relapse,  even  in  cases  not  cut  short  by  death. 


174 


TROPICAL   MEDICINE   AND   HYGIENE 


The  suddenness  of  the  rise  and  fall  of  temperature  is  a 
startling  feature  of  relapsing  fever.  Within  a  few  hours 
the  temperature  in  the  axilla  reaches  103°  F.  or  beyond. 
While  usually  showing  a  diurnal  variation  of  about  2°  F., 
being  lowest  in  the  morning,  the  temperature  remains  at 
a  high  level  throughout  the  initial  attack,  with  an  upward 
tendency  as  the  crisis  is  approached.  At  the  acme  of  the 
fever  a  temperature  of  105°  F.,  106°  F.,  or  even  higher  is 
not  uncommon,  but  as  it  is  not  long  maintained  is  of  less 
serious  import  in  this  than  in  most  other  acute  fevers. 
The  crisis,  while  usually  occurring  on  the  seventh  day  of 
the  primary  attack,  may  often  be  accelerated  or  delayed 


TIME    M    E    M|E    M    E  |M    E    M|E    MEMEMEME     M^MEMEMEME    M     E     MEMEMEMEMEME 

.lUSi^^   ~X-Ai   i       1  iti      \  72.  A  / 

N "   -"  ^-^^\                            i  vW^ 

*-    -^       -^      ^       \-                                                  V_,    ji       _ 

\l\    "                         -V 

'Z    '-                         \             ~             " 

97                                                              -   J^^                                         ^                                      A^-"* 

-f-       ^t                                           _L 

Fig.  40. — Relapsing  Fever.     Indian. 


a  day.  Rarely  the  crisis  occurs  on  the  ninth  day,  or 
still  more  rarely  on  the  fourth.  Whenever  it  occurs  the 
critical  fall  of  temperature  is  usually  very  sudden,  reach- 
ing the  normal  point  or,  more  commonly,  a  degree  or 
two  below  it  within  twelve  hours. 

The  temperature  remains  subnormal  for  two  or  three 
days,  then  rises  to  the  normal  point,  where  it  remains 
until  a  relapse  occurs.  The  course  of  the  fever  in  relapses 
is  similar  to  that  of  the  initial  attack,  tending,  however, 
to  be  less  abrupt  in  its  onset,  to  show  greater  daily 
oscillations  and  to  be  of  shorter  duration.  In  fact,  all 
the  symptoms  of  a  relapse  are  less  typical  than  those 
of   the  initial   attack.     The   interval    between    each    sue- 


KKLAl'SING    KI':VKF>:  I75 

cessive  relapse  also  tends  to  be  longer.  Thus,  while  the 
ordinary  duration  of  the  initial  attack  is  seven  days,  and 
of  the  first  apyrexial  interval  also  seven  days,  the  first 
relapse  usually  lasts  five  days  and  the  third  only  two  days, 
while  the  interval  between  them  is  commonly  nine  days. 
It  will  be  evident  that  an  attack  of  relapsing  fever  with 
only  one  relapse  lasts  nearly  three  weeks. 

Considerable  variations  may  occur  in  the  temperature 
of  relapsing  fever.  Instead  of  by  crisis,  for  example,  the 
fever  may  subside  by  lysis,  and  in  some  cases  a  secondary 
rise  may  abruptly  succeed  the  critical  fall. 

The  pulse  during  relapsing  fever  follows  the  course  of 
the  temperature,  though  with  a  tendenc}',  more  marked 
with  each  successive  relapse,  to  lag  behind.  It  rapidly 
increases  in  frequency'  with  the  onset  of  the  fever  and 
continues  to  rise,  though  less  slowly,  as  the  crisis  is 
approached.  Its  rate  commonly  reaches  120  per  minute 
during  the  first  day  of  the  disease — rather  more  than  that 
in  women  and  children — and  by  the  third  or  fourth  day 
of  fever  it  may  be  130  or  even  140  per  minute.  With 
the  crisis  the  pulse-rate  falls,  though  less  rapidly  than  the 
temperature.  It  may  be  unusually  slow  for  a  day  or  two 
following  the  crisis,  after  which  it  returns  to  normal  until 
the  relapse  sets  in. 

Although  at  first  bounding,  the  pulse  of  relapsing  fever 
soon  becomes  soft  and  compressible,  these  features 
(which  are  almost  invariable)  becoming  more  marked  in 
proportion  to  the  duration  of  the  disease. 

Corresponding  with  the  condition  of  the  pulse,  the 
heart  almost  invariably  shows  signs  of  weakness.  The 
impulse  soon  becomes  weak  and  the  first  sound  pro- 
longed and  booming.  In  rare  instances,  and  these  almost 
always  met  with  during  the  acme  of  the  initial  attack, 
sudden  heart  failure  occurs,  causing  fatal  syncope. 

Respiration  in  an  uncomplicated  case  of  relapsing  fever 
corresponds  with  the  pulse.  There  is  commonly  slight 
bronchial  conj^estion  evidenced  bv  couo'h  and  frothv 
expectoration.     With  no  further  complications  than  this, 


176  TROPICAL   MEDICINE   AND   HYGIENE 

the  breathing  may  be  very  rapid  and  the  patient  may 
suffer  from  acute  dyspnoea  at  the  acme  of  the  fever, 
which,  however,  is  quickly  reheved  with  the  fall  of 
temperature. 

A  frequent  and  serious  complication  of  relapsing  fever 
is  pneumonia,  which  may  be  either  of  the  lobar  type  or 
more  commonly  lobular. 

The  relation  of  the  two  conditions  is  liable  to  be  over- 
looked, for  while  on  the  one  hand  the  indications  of 
serious  pulmonary  inflammation  may  be  so  slight  as  to 
be  only  discovered  after  death,  on  the  other  hand  pneu- 
monia may  be  the  most  prominent  feature  of  the  illness 
and  may  modify  the  crisis  or  obscure  the  onset  of  a 
relapse.  The  onset  of  pneumonia  is  most  common 
towards  the  end  of  the  initial  attack,  but  may  be  earlier 
or  not  until  the  commencement  of  a  relapse.  It  may 
sometimes  be  indicated  by  a  diminution  in  the  severity 
of  the  general  symptoms  shortly  before  the  crisis  is  due. 
The  temperature  and  pulse-rate  fall,  breathing  becoming 
more  frequent,  and  working  of  the  alae  nasi  may  be 
observed.  The  headache  and  bodily  pains  diminish  and 
there  is  less  epigastric  discomfort.  Examination  of  the 
chest  will  reveal  the  ordinary  physical  signs  of  pneumonia. 
There  is,  however,  less  tendency  to  involvement  of  the 
bases  of  the  lungs  than  in  primary  pneumonia.  It  is 
always  accompanied  by  pleurisy. 

Reference  has  been  made  to  the  thirst,  vomiting,  and 
epigastric  discomfort  of  relapsing  fever.  The  severity  of 
the  thirst  is  often  a  striking  symptom.  It  is  associated 
with  a  dry  tongue,  which  quickly  becomes  coated  with 
brown  fur,  except  at  the  tips  and  edges.  Following  the 
crisis  the  tongue  soon  becomes  clean  and  the  thirst 
diminishes. 

Vomiting  is  a  variable  symptom.  It  is  usually  not 
serious,  but  the  irritability  of  the  stomach  may  render 
feeding  difficult  and  aggravate  the  thirst. 

The  vomited  matter  is  usually  greenish,  a  mixture  of 
bile    and     mucus,    occasionally    containing    streaks    of 


KELAPSING    FEVEK  177 

blood.       In    rare    instances    "black    vomit"    has    been 
observed. 

The  epigastric  discomfort  which  is  so  common  a 
symptom  is  due  to  catarrhal  inflammation  of  the  stomach, 
partly  also  to  active  congestion  of  the  liver  and  spleen. 

While  the  constipation  of  the  early  period  of  relapsing 
fever  is  constant  enough  to  be  of  some  diagnostic  value, 
severe  diarrhoea  not  infrequently  occurs  at  the  crisis, 
the  stools  sometimes  containing  blood. 

Occasionally  there  is  actual  dysentery,  depending  prob- 
ably upon  previous  infection. 

Pain  and  tenderness  of  the  liver  and  spleen  are 
early  symptoms.  Both  organs  are  enlarged,  the  spleen 
■especially,  and  both  rapidly  diminish  in  size  after  the 
crisis. 

Frequently  associated  with  enlargement  and  tender- 
ness of  the  liver  is  jaundice,  though  this  symptom  is 
more  common  in  some  epidemics  than  in  others.  It 
usually  commences  about  the  fifth  day  of  the  initial 
attack,  disappearing  a  few  days  after  the  crisis.  Its 
intensity  varies  greatly,  but  while  usually  slight  and 
transient  it  may  sometimes  be  very  intense. 

The  urine  is  dark  and  scanty  during  the  febrile  stages 
of  relapsing  fever,  and  also  during  the  early  part  of  the 
apyrexial  period.  It  is  of  rather  low  specific  gravity 
(loio  to  1015),  and  contains  an  excess  of  urea.  A  small 
amount  of  albumin  may  occur,  and  granular  casts  may 
be  found  ;  blood  is  uncommon.  When  jaundice  is 
present  the  urine  contains  biliary  pigments. 

Mention  has  been  made  of  the  hot,  dry  skin  of  the 
febrile  stage  and  of  the  sweating  at  the  crisis  of  relapsing 
fever.  The  skin,  though  dry,  does  not  feel  so  hot  as  might 
be  expected  from  the  bodily  temperature,  thus  dift'ering 
from  the  condition  observed  in  certain  other  acute  febrile 
diseases,  pneumonia  for  example. 

The  critical  sweats  are  usually  very  profuse,  even  more 
so  than  in  malaria,   and   may  saturate  the    clothes   and 
bedding. 
12 


1 78   ,  TROPICAL   MEDICINE   AND   HYGIENE 

Night  sweats  sometimes  occur  after  the  crisis,  and 
during  relapses  the  skin  may  often  be  moist. 

While  there  is  usually  no  rash  in  relapsing  fever,  facial 
herpes  is  not  uncommon.  In  certain  cases  small  rose- 
coloured  spots,  something  like  those  of  enteric  fever,  but 
smaller,  are  met  with.  They  come  out  in  crops,  which^ 
commencing  near  the  crisis  of  fever,  may  continue  into 
the  apyrexial  period.  These  papules  are  most  common 
on  the  front  and  sides  of  the  chest  and  abdomen.  They 
are  never  very  numerous,  last  only  a  few  days,  and 
disappear  on  pressure  without  leaving  a  stain. 

Sudamina  are  common,  and  in  rare  cases  petechias  are 
met  with. 

Desquamation,  except  in  the  form  of  minute  branny 
scales  following  sudamina,  is  uncommon. 

Complications. — The  more  important  complications  of 
relapsing  fever  are  pneumonia,  severe  diarrhoea,  or  dysen- 
tery, and  have  already  been  dealt  with. 

Mention  may  here  be  made  of  the  liability  of  a  small! 
proportion  of  cases  to  haemorrhages.  Epistaxis  at  the 
acme  of  fever  is  the  most  common  example.  Haema- 
temesis  may  also  occur,  and  more  rarely  cerebral 
haemorrhage,  always  fatal,  has  been  observed. 

Swelling  and  inflammation  of  the  parotid  gland  and  of 
lymphatic  glands,  most  commonly  those  of  the  inguinal 
regions,  have  been  observed  occasionally.  This  is  of 
importance  in  connection  with  the  differentiation  of  the- 
disease  from  plague. 

Inflammatory  affections  of  the  eye  and  ear  sometimes- 
occur,  but  are  rarely  serious  in  the  Indian  variety. 

Inflammation  of  serous  membranes  are  rare,  but  slight 
painful  swelling  of  some  of  the  joints,  most  commonly 
those  of  the  upper  limb,  are  not  uncommon. 

Pregnant  women  always  abort;  the  abortion  is  gener- 
ally followed  by  recovery. 

The  coexistence  of  relapsing  fever  with  malaria,  small- 
pox, measles,  plague,  and  diphtheria  has  been  noticed, 
and  in  certain  epidemics,  following  famines,  with  scurvy. 


RELAPSING    FEVER  179 

There  are  no  special  seqnehc  of  relapsinj:^  fever,  though 
mental  and  bodily  weakness  frequently  persist  for  some 
time. 

Propjwsis. — The  prognosis  of  an  uncomplicated  case 
of  relapsing  fever  is  good.  The  mortality  varies  in 
different  epidemics,  probably  depending  upon  the  con- 
dition of  the  infected  population.  When  the  disease 
prevailed  in  Great  Britain  the  mortality  was  estimated  at 
about  4  per  cent.  A  similar  rate  is  said  to  be  common 
in  Russia.  In  Bombay,  however,  Vandyke  Carter  found 
that  the  mortality  was  18  per  cent.  His  statistics  were, 
however,  based  upon  hospital  experience.  The  death-rate 
amongst  cases  treated  in  the  municipal  hospital  in  Bom- 
bay during  the  last  ten  years  has  been  much  higher  than 
this,  something  like  30  to  40  per  cent.,  and  Choksy  re- 
cords 2,832  deaths  out  of  9,275  cases,  from  1898-1907,  an 
average  mortality  of  30'6,  but  in  the  northern  parts  of 
India  the  mortality  is  not  high. 

Death  is  most  likely  to  occur  during  the  acme  of  the 
initial  attack  and  may  be  due  to  collapse  or  to  heart 
failure,  or  may  occur  during  collapse  following  the  crisis. 
The  risk  is  greater  in  the  first  attack.  As  might  be 
expected,  extremes  of  age  are  unfavourable. 

The  case  mortality  is  slightly  higher  among  women 
than  among  men,  though  abortion  is  usually  followed  by 
recovery. 

In  cases  complicated  by  pneumonia  the  prognosis  is 
unfavourable,  recovery  being  rare. 

Severe  jaundice  also  renders  the  prognosis  unfavour- 
able, and,  as  has  been  seen,  cerebral  haemorrhage  is  alwavs 
fatal. 

Diagnosis. — While  a  typical  case  of  relapsing  fever  is 
easily  recognized,  instances  occur  in  which  it  is  impossible 
to  arrive  at  a  correct  diagnosis  by  means  of  the  clinical 
signs  alone,  and  the  real  nature  of  the  disease  may  quite 
easily  be  overlooked,  even  at  the  autopsy.  It  can  be 
understood,  also,  that  a  patient  seen  for  the  first  time  at 
the  acme  of  the  fever  or  at  the  crisis  might  be  thought  to 
be  suffering  from  malaria,  while,  but  for  the  occurrence 


l8o  TROPICAL   MEDICINE   AND   HYGIENE 

of  the  crisis,  the  diagnosis  in  severe  cases  might  well  be 
that  of  septicaemic  plague,  especially  should  death  ensue. 
It  may  be  added  that  the  pneumonic  form  of  plague  may 
resemble  that  of  relapsing  fever,  though  it  is  usually 
much  more  severe,  and  the  very  abundant  prune  juice 
sputum,  seen  in  pneumonic  plague,  is  characteristic  when 
it  occurs. 

It  is  quite  possible  that  cases  of  relapsing  fever  accom- 
panied by  severe  jaundice  and  bloody  vomiting,  occurring 
in  countries  in  which  yellow  fever  prevails,  might  easily  be 
mistaken  for  that  disease.  The  discovery  of  the  Spirillum 
obernieieri  in  the  blood  is  therefore  sometimes  the  only 
means  by  which  a  positive  diagnosis  can  be  arrived  at. 

It  is  essential,  therefore,  that  all  cases  in  which  the 
diagnosis  of  relapsing  fever  is  doubtful  the  blood  should 
be  carefully  examined  for  this  parasite.  Moreover,  in 
view  of  the  differences  which  have  been  described  in  the 
spirilla  of  relapsing  fever  cases  occurring  in  different 
parts  of  the  world,  and  of  the  discovery  of  a  similar 
parasite  in  the  blood  of  persons  suffering  from  African 
tick  fever,  the  examination  of  the  blood  in  cases  in  which 
the  clinical  diagnosis  has  been  well  established  is  of  great 
interest  and  importance.  It  should  be  remembered  that 
the  spirillum  can  usually  be  found  in  the  blood  only 
during  the  febrile  period,  as  it  disappears  at  the  crisis  and 
reappears  only  with  the  onset  of  a  relapse.  This  state- 
ment is  not  absolute,  however,  for  cases  are  not  infrequent 
in  which  spirilla  have  been  discovered,  though  in  greatly 
diminished  numbers,  in  the  blood  of  patients  during  the 
early  part  of  the  apyrexial  period.  For  the  discovery  of 
the  spirilla,  either  fresh,  unstained,  or  dry-stained  films 
may  be  used.  In  either  case  the  search  may  be  easy  or 
difficult,  depending  upon  the  number  of  parasites  present, 
this  varying  greatly.  In  some  cases  they  may  be  so 
numerous  as  to  make  the  whole  of  the  field  of  the 
microscope  seem  in  active  motion,  while  in  others  careful 
search  of  stained  films  is  necessary  to  discover  any. 

The  best  staining  method  is  probably  Leishman's  or 


RELAPSING    FEVER  lOI 

other  modification  of  Romanovvsky's  stain.  Failin^f  this, 
gentian  violet  or  carbol-fuchsin  may  be  used.  The  spiril- 
lum is  described  under  the  heading  of  Etiology,  p.  183. 
The  blood  of  patients  suffering  from  relapsing  fever 
shows  a  condition  of  leucocytosis.  The  number  of  both 
polymorphonuclear  and  mononuclear  leucocytes  is  in- 
creased. Sometimes  this  is  very  marked,  and  as  there 
is  also  a  diminution  in  the  number  of  red  corpuscles  the 
excess  of  these  over  the  leucocytes  is  greatly  reduced. 

The  spirillum  has  not  been  demonstrated  in  any  of  the 
patient's  secretions  or  excretions. 

Morbid  Anatomy. 

The  bodies  of  patients  dying  of  uncomplicated  relapsing 
fever  do  not  show  any  very  characteristic  gross  changes. 
The  condition  is  that  of  a  general  septicaemia  with  en- 
largement of  the  spleen  and  liver  and  catarrhal  inflamma- 
tion of  the  stomach — often  also  of  the  intestines  and 
of  the  bronchi.  Subserous  haemorrhages  under  the 
peritoneum,  pericardium,  and  pleura  are  common.  The 
enlargement  of  the  spleen  is  usually  very  considerable, 
its  weight  sometimes  reaching  5  lb.,  and  its  size  exceed- 
ing the  normal  by  five  or  six  times. 

The  splenic  capsule  is  distended  and  smooth,  and  the 
whole  organ  is  rounded.  The  spleen  substance  shortly 
after  death  is  firm  and  dark  mottled  with  small  white 
spots,  which  are  the  enlarged  Malpighian  corpuscles ; 
these  may  sometimes  be  breaking  down  into  minute 
abscesses.  Large  wedge-shaped  infarcts  are  common, 
usually  having  their  base  at  the  capsule,  though  they  may 
be  met  throughout  the  organ.  When  recently  formed  they 
are  of  a  dark  red  colour,  but  later  they  become  pale  and 
may  be  found  breaking  down  into  pus. 

Microscopically  the  hypertrophy  of  the  spleen  is  found 
to  be  due  both  to  proliferation  of  its  cellular  elements — 
especially  of  the  Malpighian  corpuscles — and  to  vascular 
engorgement.  Spirilla  may  be  found  in  the  spleen  both  free 
and  in  polymorphonuclear  cells,  often  in  great  profusion. 


l82  TROPICAL   MEDICINE   AND   HYGIENE 

The  enlargement  of  the  hver  is  often  marked  and  the 
weight  may  be  as  much  as  5  lb.  Though  sometimes 
dark  and  congested,  it  is  more  commonly  pale  and 
mottled.  Its  substance  is  soft  and  the  lobules  are  in- 
distinct.    There  is  cloudy  swelling  of  the  cells. 

Besides  the  conditions  mentioned,  the  heart  is  usually 
found  to  be  pale  and  soft,  the  muscular  fibres  showing 
signs  of  cloudy  swelling  and  sometimes  fatty  degenera- 
tion. The  kidneys  and  other  abdominal  organs  are  also 
in  the  condition  of  cloudy  swelling.  The  inflammation 
of  the  intestinal  tract  is  often  considerable.  The  stomach 
is  the  part  most  commonly  affected  and  there  are  usually 
numerous  small  haemorrhages  beneath  the  mucous 
membrane. 

.  In  cases  complicated  by  diarrhoea  or  dysentery  there 
is  intense  congestion  of  the  ileum  and  colon,  which  may 
even  be  superficially  ulcerated.  A  certain  amount  of 
bronchial  catarrh  is  usually  found,  but  in  uncomplicated 
cases  the  lungs  are  pale. 

Two  forms  of  pneumonic  consolidation  may  be  met 
with.  The  more  common  form  is  that  in  which  patches 
of  consolidation,  often  of  considerable  size,  are  scattered 
through  both  lungs ;  they  may  be  met  with  in  any  part 
of  the  lobes  and  are  not  more  common  at  the  bases  than 
elsewhere.  The  other  form  of  consolidation  is  similar  to 
that  of  ordinary  croupous  pneumonia. 

While  inflammation  of  the  brain  or  its  meninges  is  rare 
in  relapsing  fever,  passive  congestion  as  shown  by  venous 
engorgement  and  serous  exudation  is  not  uncommon. 

Etiology. — Relapsing  fever  is  remarkable  in  being  the 
first  disease  shown  to  be  due  to  a  micro-organism. 
During  an  epidemic  in  Berlin,  in  1868,  Obermeier  dis- 
covered in  the  blood  of  patients  suffering  from  relapsing 
fever  a  spirillum,  which  since  the  publication  of  the 
discovery  in  1873  has  been  accepted  as  the  cause  of  the 
disease.  These  spirilla  are  now  commonly  termed 
spirochaetae. 
.  The  Spirillum  obenneieri  or  S.  recurrentis  is  a  delicate 


KELAPSING    FEVEK 


183 


wavy  thread  measuring  between  15  ^  and  40 /x  in  len^^th 
by  about  '25  fju  in  breadth  at  its  widest  part.  The  num- 
ber of  spirals  varies  greatly,  as  also  does  their  contour.  A 
common  number  of  spirals  is  eight,  but  often  two  spirilla 
are  joined  together,  giving  the  appearance  of  one  long 
form  with  sixteen  spirals.  Sometimes  the  spirals  may  be 
short,  giving  a  corkscrew  appearance,  or  they  may  be 
only  slight  undulations.  In  thick  films  the  spirilla  may 
be  in  bold  curves  or  figures  of  eight,  with  few  or  no 
undulations  (fig.  41), 


Fig.  41. 

No  details  of  structure  can  be  made  out  except  that 
it  has  tapering  pointed  ends,  and  that,  especially  when 
stained  by  Romanowsky's  method,  slight  difference  in  the 
degree  of  staining  of  different  parts  can  be  noted,  the 
central  part  staining  least.  Some  observers  have  de- 
scribed a  delicate  terminal  flagellum ;  the  presence  of 
flagella  is  denied  by  most  observers.  A  striking  feature 
of  the   organism   is  its   extraordinary  motility,   which   is 


184  TROPICAL  MEDICINE  AND   HYGIENE 

progressive  as  well  as  rotary  and  lateral.  It  is  best 
stained  by  aniline  dyes,  especially  by  some  modification 
of  Romanowsky's  stain,  and  also  by  carbol-fuchsin  and 
gentian  violet.     It  is  decolorized  by  Gram's  method. 

When  faintly  stained  by  Romanowsky's  method  the 
parasite  is  blue,  if  the  staining  is  prolonged  it  becomes 
red.  All  attempts  to  cultivate  it  have  failed,  but  it  can 
be  kept  alive  in  citrated  blood  outside  the  body  for 
several  days.  Tictin  found  the  spirillum  in  bugs  fed 
upon  patients  suffering  from  relapsing  fever  and  showed 
that  they  could  survive  in  them  for  seventy-seven  hours. 
He  also  succeeded  in  infecting  monkeys  with  the  fluids  of 
such  bugs  crushed  immediately  after  feeding,  but  when 
bugs  had  been  killed  forty-eight  hours  after  feeding  their 
fluids  were  not  infective,  although  the  S.  obermeieri 
could  be  found  in  stained  preparations.  Karlinsky,  in 
infected  houses,  found  the  spirillum  in  bugs,  and  that  the 
spirilla  could  live  in  these  for  thirty-nine  days. 

Blood  containing  the  spirillum  has  been  frequently 
inoculated  into  man,  both  deliberately  and  by  accident, 
and  has  caused  relapsing  fever.  Various  kinds  of 
monkeys  have  also  been  successfully  inoculated.  Until 
recently  man  and  monkeys  were  considered  to  be  the 
only  susceptible  animals,  but  Novy  and  Knapp  have 
recorded  the  successful  inoculation  of  white  mice  in 
which  relapses  occurred,  and  of  white  rats. 

The  incubation  period  following  inoculation  in  man 
is  usually  between  thirty  and  thirty-six  hours. 

There  has  been  a  good  deal  of  speculation  as  to  the 
interdependence  between  the  presence  of  spirochaetes 
and  the  different  phases  of  relapsing  fever.  An  early 
view  was  that  the  fever  resulting  from  the  presence  of 
the  parasite  in  the  blood  caused  its  destruction  and 
that  relapses  were  due  to  the  development  of  further 
generations  of  spirilla  from  spores.  The  existence 
of  spores  of  S.  obermeieri  has,  however,  not  been 
demonstrated.  The  blood  of  a  patient  during  the 
apyrexial   intervals   will  still  infect   monkeys  if   injected 


RELAPSING    FEVER  1 85 

into  tlieiii.  Another  view  attributed  tiie  disappearance 
of  spirilla  to  the  formation  in  the  blood  of  some  bacteri- 
cidal a^^ent  at  this  crisis,  while  a  more  modern  view  is  that 
the  spirilla  are  destroyed  by  phagocytosis,  this  destruction 
occurring  chiefly  in  the  spleen.  Th<i  lengthening  periods 
of  interruption  and  the  mildness  of  relapses  is  by  others 
attributed  to  the  acquirement  by  the  patient  of  increas- 
ing degrees  of  immunity.  This  view  is  consistent  with 
the  probable  protozoal  nature  of  the  parasite.  The 
spirillum  or  S.  oheiineicri  is  one  of  a  class  of  organisms 
of  which  many  pathogenic  species  are  known.  These 
mentioned  in  the  order  of  their  discovery  include 
S.  anscriiii,  the  cause  of  septicaemia  of  geese ;  S.  Iheilcri, 
affecting  cattle  in  South  Africa ;  S.  gallinariiui,  causing 
fever  in  fowls  in  Brazil,  the  Soudan,  and  elsewhere,  and 
S.  duttoni,  the  cause  of  African  tick  fever.  These  organ- 
isms resemble  each  other  in  their  general  morphology 
and  active  motility.  They  all  occur  free  in  the  circu- 
lating blood  during  the  febrile  paroxysm  and  all  have 
hitherto  resisted  attempts  to  cultivate  them  in  artificial 
media. 

It  has  furthermore  been  demonstrated  that  certain  of 
them  are  conveyed  by  the  bite  of  certain  ticks ;  thus, 
S.  gallinannn  is  transmitted  by  Argas  persicus,  S.  tJieilcri 
by  Boophiliis  decoloratiis,  and  S.  diittoui  by  OniiiJiodonts 
moubata.  No  such  demonstration  has  been  made  in  the 
case  of  Indian  aud  European  relapsing  fever,  but  a  tick 
very  similar  to  0.  uwiihata — 0.  savignyi — has  been  shown 
to  occur  in  India. 

Mackie  reports  an  epidemic  in  a  school  in  India,  in 
which  he  believed  the  transmitting  agent  was  Pcdicuhis 
vestimentonuu  (fig.  42).  The  disease  was  much  more 
prevalent  in  the  boys  who  were  infested  with  pediculi 
than  in  the  girls  who  were  less  so.  Fourteen  per  cent. 
of  the  lice  from  the  boys  W'cre  infected,  and  2*7  per  cent. 
from  the  girls.  Spirochaetes  were  found  in  the  secretion 
expressed  from  the  mouths  of  the  infected  pediculi. 

Brief   mention    may   be    made  of  certain  other   spiro- 


l86  TROPICAL   MEDICINE   AND   HYGIENE 

chaetes,  such  as  S.  vincenti,  found  in  certain  forms 
of  gangrenous  inflammation ;  S.  pallida,  described  by 
Schaudinn  in  syphilitic  lesions  and  believed  to  be  the 
cause  of  this  disease  ;  and  others  found  in  the  mouth,  in 
smegma,  in  tropical  ulcers,  and  in  certain  tumours  in 
mice.  Whether  the  last  two  have  any  pathological  signifi- 
cance is  not  known. 

The  question  as  to  whether  spiroch^etes  are  protozoa  or 
bacteria  cannot  be  fully  discussed  here.     Formerly  they 


Fig.  42. — Pediculus  vestimentorujii, 

were  considered  to  be  bacteria.  As  long  ago,  however, 
as  1888,  Tamilensky  suggested  that  the  S.  obenneieri  might 
be  only  a  stage  of  a  haemocytozoon,  and  since  1904,  when 
Schaudinn  suggested  that  spiroch^etes  should  be  con- 
sidered as  protozoa,  this  view  has  been  generally  accepted. 
More  recently  (1906)  Novy  and  Knapp  have  disputed 
Schaudinn's  conclusions,  asserting  that  he  was  mistaken 
in  his  observations,  and  reclassifying  the  spirochaetes 
as  bacteria. 

The  question  must  for  the  present,  therefore,  be  con- 
sidered an  open  one,  but  it  is  of  interest  to  note  that  the 


RELAPSING   FEVEK  187 

known  p:itho|^fcnic  species  have  certain  features  strikingly 
resembling  those  of  organisms  concerning  the  inclusion 
of  which  among  the  protozoa  there  can  be  no  dispute. 
These  features  are  the  constancy  and  intensity  of  the 
blood  infection,  and,  in  the  case  of  some  at  least,  the 
transmission  by  alternative  hosts. 

A  remarkable  feature  in  the  etiology  of  relapsing  fever 
is  the  fact  that  although  its  local  infectivity  is  very  marked 
it  does  not  spread  widely  except  among  populations  living 
under  uncleanly  conditions.  Thus,  when  outbreaks 
occurred  in  English  towns,  they  were  almost  entirely 
confined  to  the  Irish,  and  in  the  Bombay  epidemics 
described  by  Vandyke  Carter,  the  disease  only  affected 
overcrowded  localities.  It  may,  however,  spread  to 
other  patients  in  a  moderately  well-managed  institu- 
tion or  hospital  in   the  Tropics. 

At  one  time  famine  was  considered  to  play  such  an 
important  part  in  the  etiology  of  this  disease  as  to  give 
it  the  name  of  "  famine  fever."  While,  however,  famine- 
stricken  individuals  may  offer  less  resistance  to  infection, 
it  has  not  infrequently  been  found  that  attacks  have 
occurred  in  the  absence  of  any  such  conditions,  as,  for 
example,  among  bodies  of  workmen  in  receipt  of  good 
pay  but  living  in  dirty  and  overcrowded  quarters. 

The  liability  to  attack  of  attendants  on  the  sick  has  long 
been  recognized.  Doctors,  nurses,  students  and  hospital 
servants  are  frequent  sufferers ;  laundry  hands  come 
under  the  same  category. 

Instances  of  place  infection  are  common,  successive 
occupants  of  a  house,  room,  or  ship  being  attacked,  and 
the  introduction  of  cases  into  a  hospital  has  led  to  cases 
among  other  patients.  An  interesting  example  of  ship- 
infection  is  furnished  by  the  S.S.  "Caledonia,"  in  which 
cases  of  relapsing  fever  occurred  in  London  in  October, 
1905,  and  again  in  June,  1906,  these  being  the  only  cases 
known  in  this  port  during  those  years. 

Trcatinciit. — There  is  no  specific  treatment  for  relapsing 
fever.     Quinine,  eucalyptus,  the  salicylates,  arsenic,  iodide 


l88  TROPICAL   MEDICINE   AND   HYGIENE 

of  potassium,  and  a  variety  of  drugs  have  been  tried  with 
the  object  of  cutting  short  the  disease,  but  without  effect. 
Treatment  with  the  serum  of  hyperimmunized  animals  is 
more  promising. 

As  in  all  specific  fevers,  the  patient  should  be  confined 
to  his  bed  in  a  well-ventilated  room,  and  his  strength 
should  be  maintained  by  careful  feeding. 

A  point  calling  for  special  mention  is  the  necessity  for 
prompt  and  liberal  stimulation  on  the  earliest  indication 
of  heart  failure  or  collapse.  The  early  use  of  alcohol  in 
moderate  doses  is  advisable,  and  may  be  combined  with 
strychnine.  The  collapse  of  the  crisis  is  best  met  by  hot 
drinks,  e.g.,  hot  brandy  or  whisky  and  water,  and  by  hot 
blankets  and  hot- water  bottles. 

High  temperature,  per  se,  does  not  usually  call  for 
special  treatment  in  relapsing  fever.  Antipyretic  drugs 
exert  little  effect  upon  it,  and  should  be  avoided  on 
account  of  their  depressing  action  upon  the  heart.  Tepid 
or  cold  sponging  may,  however,  be  beneficial,  the  choice 
depending  upon  the  height  of  the  fever. 

Thirst  and  vomiting  may  both  be  relieved  by  the 
frequent  administration  of  small  quantities  of  cold  but 
not  iced  water.  It  is  further  important  to  let  the  patient 
have  plenty  of  water  or  other  cooling  drinks,  provided 
that  they  do  not  cause  vomiting.  The  vomiting  may 
require  the  application  of  a  mustard  plaster  or  other 
counter-irritant  to  the  epigastrium,  this  also  relieving  the 
tenderness  of  the  liver  and  spleen. 

In  view  of  the  tendency  to  relapse,  and  thus  to  con- 
siderable duration  of  the  disease,  it  is  very  necessary  to 
see  that  the  patient  is  properly  fed.  During  the  febrile 
period  fluids  only  should  be  given.  The  best  is  milk 
diluted  with  soda-water,  or  with  lime  or  barley  water. 
During  the  apyrexial  period,  should  there  be  no  intestinal 
complications,  solid,  easily  digestible  food  may  be  given. 

The  constipation  of  the  early  stage  is  best  treated  by  a 
mild  aperient,  but  in  view  of  the  tendency  to  diarrhcea 
at  the  crisis,  it  is  important  to  avoid  violent  measures. 
For  the  headache  and  insomnia,  cold  applications  to  the 


RELAPvSING    FEVEK  189 

head  and  small  doses  of  bromide  and  chloral  aic  the 
best  remedies.  The  treatment  of  other  symptoms  and  of 
complications  shonld  be  conducted  on  i^cneral  [principles 
and  does  not  call  for  special  remedies. 

Preventive  Treahnent. — From  what  has  been  said  with 
regard  to  the  etiology  of  relapsing  fever  it  would  appear 
that  cleanliness  of  the  person's  clothes  and  dwelling 
and  the  destruction  of  vermin  are  the  best  safeguards 
against  the  disease.  From  an  administrative  point  of 
view  the  condition  to  be  prevented  or  overcome  is  that 
of  overcrowding,  for  it  is  only  under  this  condition, 
whether  it  be  in  city  or  camp,  that  epidemics  occur. 
Should  it  be  impossible  to  avoid  overcrowding,  it  is 
important,  in  view  of  the  probability  of  the  transmis- 
sion of  infection  by  means  of  pediculi,  bugs,  or  similar 
blood-sucking  parasites,  to  see  that  the  houses  of  the 
poor  are  kept  free  from  dry  dust,  which  harbours  such 
parasites.  Should  outbreaks  occur  the  patients  should 
be  isolated,  and  the  clothing,  bedding,  furniture  and 
dwellings  of  the  patients  and  their  associates  should  be 
disinfected.  In  the  disinfection  of  furniture  and  dwellings, 
it  is  important  to  ensure  that  the  disinfectant  penetrates 
all  cracks  and  crevices  and  destroys  the  insects  and  other 
parasites  and  their  larv?e  which  harbour  in  such  places. 
Infected  native  huts  should  be  burnt  when  it  is  possible. 

Before  a  patient  is  admitted  to  the  wards  of  a  hospital 
his  person  and  clothes  should  be  freed  from  external 
parasites.  In  view  of  the  possible  transmission  of  infec- 
tion otherwise  than  by  external  parasites,  it  is  wise  not 
to  admit  relapsing  fever  patients  to  the  general  ward  of 
a  hospital,  and  though  active  spirochcetes  have  not  been 
discovered  in  any  of  the  secretions  or  excretions,  it  is 
wise  to  adopt  the  same  precautions  in  dealing  with  them 
as  in  the  case  of  other  infective  diseases. 

It  is  important  to  k'eep  the  patient  either  in  hospital  or 
under  observation  for  at  least  fourteen  days  after  the 
cessation  of  fever.  This  is  in  order  to  avoid  any  danger 
of  his  again  becoming  a  source  of  infection  should  a 
relapse  occur. 


190 


CHAPTER  XIV. 
TICK  FEVER. 

African  Relapsing  Fever. 

An  acute  specific  fever  closely  resembling  relapsing 
fever  both  in  its  symptoms  and  in  being  associated  with 
the  presence  of  spirochsetes  in  the  blood.  Infection  is 
transmitted  by  the  bite  of  a  tick. 

Tick  fever  occurs  throughout  the  greater  part  of 
Tropical  Africa.  Livingstone  and  other  early  travellers  in 
Central  Africa  have  recorded  the  occurrence  of  a  fever 
attributed  by  natives  to  the  bites  of  a  certain  tick,  Ornitho- 
dorus  moubata.  The  disease  was  well  known  to  the 
Portuguese  and  other  European  inhabitants  of  the  upper 
reaches  of  the  Zambesi  and  in  Central  Africa,  but  it  was 
not  till  1903  that  Philip  Ross  and  Hodges,  working  in 
Uganda,  discovered  in  the  blood,  first  of  an  Indian,  and 
later  of  Africans  and  of  one  European,  suffering  from 
symptoms  similar  to  those  of  relapsing  fever,  a  spirillum 
which  they  considered  was  probably  identical  with 
Spirocliceta  obermeicri.  Following  up  this  discovery, 
Philip  Ross  in  1904  demonstrated  the  presence  of  a  spiril- 
lum in  the  blood  of  several  natives  of  Uganda  suffering 
from  an  illness  which  they  ascribed  to  the  bites  of  ticks. 

In  1904  Button  and  Todd,  working  in  the  Congo  Free 
State,  also  met  with  cases  of  tick  fever,  and  showed 
that  it  was  due  to  a  spirillum  which  they  also  thought 
was  probably  identical  with  S.  obermeieri.  They  were 
further  able  to  reproduce  the  disease  in  monkeys  by 
submitting  them  to  the  bite  of  the  ticks  which  had  been 
caught  in  native  houses,  or  which  had  been  reared  from 


TICK    FEVEK  191 

the  e^gs  of  such  ticks.  These  ticks  were  also  idenlified 
as  0.  moubata.  Button  and  Todd  also  gave  the  disease 
to  monkeys,  guinea-pigs  and  rats  by  injection  of  infected 
blood. 

They  were  not  able  to  find  spirochaetes  in  the  ticks 
which  transmitted  the  fever  to  monkeys,  but  Koch  shortly 
afterwards,  in  German  East  Africa,  demonstrated  them 
not  only  in  infected  ticks  but  also  in  their  eggs. 

Koch  also  successfully  infected  mice  and  rats  by  the 
bites  of  infected  ticks. 

Recently  Breinl  and  Kinghorn,  working  at  Liverpool 
with  ticks  infected  in  the  Congo  Free  State,  have  been 
able  to  infect  a  number  of  laboratory  animals  with  the 
spirochaete.  While  they  were  unable  to  separate  this 
spirochaste  from  the  S.  obenneieri  by  any  morphological 
differences,  they  showed  that  each  spirochaete  conferred 
immunity  against  itself  but  not  against  the  others. 

They  therefore  considered  the  spirochaetes  to  be 
distinct  species  and  named  that  causing  tick  fever 
S.  didtoni.  Attempts  to  transmit  these  mfections  by  bed 
bugs  failed.  The  symptoms  produced  in  animals  by 
inoculation  of  these  two  different  species  of  spirochaetes 
are  very  similar,  but  there  are  slight  differences.  Inocu- 
lation of  S.  dutioni  produced  a  much  more  serious  illness 
than  that  caused  by  S.  obenneieri,  often  causing  death, 
while  no  animals  died  of  infection  with  the  latter 
parasite.  In  monkeys  inoculated  with  S.  dutioni,  the 
incubation  period  was  usually  shorter,  the  pyrexial  attacks 
longer  and  the  relapses  more  frequent  than  in  those 
inoculated  with  S.  obenneieri. 

The  symptoms  of  tick  fever  in  man  resemble  very 
closely  those  of  relapsing  fever,  so  much  so  that  Button 
and  Todd,  from  their  experience  of  it  in  the  Congo  Free 
State,  expressed  the  opinion  that  the  two  diseases  were 
clinically  identical.  The  sudden  access  of  high  fever, 
the  headache,  pains  in  the  back  and  limbs,  prostration, 
thirst,  and  vomiting  are  as  characteristic  of  tick  fever  as 
of  relapsing  fever,  as  also  the  sudden  crisis  with  profuse 


192  TROPICAL   MEDICINE   AND   HYGIENE 

sweating,  followed  by  an  apyrexial  period,  and  this  again 
by  one  or  more  relapses.  Enlargement  and  tenderness 
of  the  liver  and  spleen  are  symptoms  common  to  both 
diseases,  and  herpes  and  epistaxis  are  frequently  met  with 
in  both.  Tick  fever  differs  from  relapsing  fever  chiefly  in 
that  the  duration  of  attack  is  usually  shorter,  four  days  or 
less  instead  of  seven,  with  comparatively  longer  apyrexial 
intervals  and  more  frequent  relapses.  Diarrhoea  is  the 
rule  in  tick  fever,  while  constipation  is  almost  always  a 
marked  symptom  of  the  early  stage  of  relapsing  fever. 
Jaundice  is  rarer  and  iritis  commoner  than  in  Indian 
relapsing  fever. 

A  slight  degree  of  bronchitis  is  common  and  pneu- 
monia is  also  met  with.  As  in  relapsing  fever,  spirochjetes 
are  usually  found  in  the  blood  of  patients  suffering  from 
tick  fever  only  during  the  pyrexial  period.  Of  the  two 
diseases  tick  fever  is  the  less  severe,  and  death  is  rare 
among  persons  who  were  in  good  health  previous  to 
attack.  It  is  said  to  be  more  severe  in  Europeans  than 
negroes,  this  probably  depending  upon  partial  immunity 
resulting  from  previous  attacks  in  the  latter.  Facial  para- 
lysis is  not  uncommon  after  an  attack. 

The  incubation  period  of  tick  fever  is  commonly 
about  five  days,  but  may  be  shorter  or  longer,  the  dura- 
tion perhaps  depending  upon  the  severity  of  infection. 

Diagnosis. — Before  the  discovery  of  the  spirochaeta  in 
the  blood  many  cases  of  tick  fever  were  considered  to 
be  suffering  from  malaria,  pneumonia  or  other  diseases. 
As  in  the  case  of  relapsing  fever,  a  correct  diagnosis  is 
often  impossible  without  the  demonstration  of  the  spiro- 
chaste  in  the  blood.  From  what  has  been  said  of  the 
symptoms  of  the  disease,  as  well  as  of  the  morphology 
of  the  parasites,  it  is  obvious  that  the  differentiation  of 
tick  fever  or  relapsing  fever  may  sometimes  be  impossible 
without  resort  to  experimental  inoculation  of  animals. 

In  the  autopsy  of  the  fatal  case  which  Button  and 
Todd  met  with,  the  liver  and  spleen  were  enlarged,  the 
heart  muscle  showed  slightly  fatty  change,  the  lungs  were 


TICK    FKVKR  I93 

pale  but  otherwise  normal  and  the  kichieys  were  enlarged 
and  showed  fatty  degeneration.  The  other  organs 
examined  appeared  normal,  but  there  was  some  blood- 
stained fluid  in  the  abdomen.  The  blood  was  fluid  and 
resembled  blood-stained  water.  Spirochcctes  were  found 
in  it  at  the  time  of  the  autopsy. 

In  animals  dying  of  tick  fever  the /'os^-;/ior/6';7/  appear- 
ances are  similar  to  those  observed  in  relapsing  fever 
in  man.  Thus,  in  post  mortems  on  monkeys,  Brienl  and 
Kinghorn  found  the  spleen  to  be  greatly  enlarged,  deeply 
congested  and  very  soft.  It  often  contained  hasmor- 
rhagic  infarcts  and  necrotic  areas  ;  similar  changes  were 
found  in  the  liver  ;  the  lungs  were  oedematous  and  con- 
tained infarcts  and  the  heart  muscle  was  much  degenerated. 
The  lymphatic  glands  were  frequently  haemorrhagic  and 
all  organs  showed  signs  of  congestion.  Spirochaetes  were 
found  in  the  spleen  and  bone-marrow  and  also  in  other 
organs. 

The  etiology  of  tick  fever  is  indicated  by  its  names,  i.e., 
tick  fever  and  African  relapsing  fever.  As  the  parasite 
can  be  cultivated  outside  the  body  in  special  media  such 
as  mouse  broth,  with  mouse  blood  and  yolk  of  egg, 
all  of  Koch's  requirements  for  proving  that  the  disease  is 
due  to  the  S.  duitoni  have  been  fulfilled.  Previously,  in 
view  of  the  fact  that  infection  can  be  transmitted  bv  the 
offspring  of  ticks  which  have  fed  upon  patients,  even  this 
condition  was  practically  complied  with.  The  sub- 
cultures retain  their  virulence. 

That  infection  is  ordinarily  transmitted  bv  ticks — the 
0.  nioubaia — admits  of  little  or  no  doubt.  It  is,  however, 
of  some  interest  to  mention  that  although  negroes  have 
long  persisted  in  attributing  this  role  to  the  ticks,  Euro- 
pean medical  men  were  unable  to  demonstrate  it  as  a 
fact  until  quite  recently.  It  has  been  seen  that  infection 
can  also  be  conveyed  by  direct  inoculation  of  blood  con- 
taining the  spiroch^ete.  So  far  no  other  means  of  infec- 
tion is  known,  and  it  has  already  been  mentioned  that 

13 


194  TROPICAL   MEDICINE    AND    HYGIENE 

attempts  to  transmit  the  disease  by  other  parasites  than 
ticks,  namely  bugs,  have  been  unsuccessful. 

Infected  ticks  can  transmit  the  disease  either  immedi- 
ately or  by  means  of  their  progeny  after  an  interval  of 
weeks  and  months ;  the  limit  of  the  infectivity  of  such 
ticks  is  at  present  unknown. 

There  are  certain  further  points  of  importance  in  con- 
nection with  the  propagation  of  tick  fever.  These  are 
that  ticks  may  transmit  infection  from  animals  which 
they  bite  during  apyrexial  periods,  when  no  spirochsetes 
can  be  discovered  in  the  blood  ;  that  the  blood  which 
has  been  passed  through  a  Berkefeld  filter  remains  infec- 
tive ;   and  that  a  period  of  immunity  follows  infection. 

The  first  two  of  these  facts  indicate  that  infection  may 
be  conveyed  by  some  other — possibly  a  developmental — 
form  of  the  spirochaete,  while  these  last  may  explain  the 
transmission  of  the  disease  from  an  apparently  healthy 
person.  Experiments  have  been  made  with  a  view  to 
obtaining  preventive  and  curative  sera  for  tick  fever.  All 
that  can  be  said  at  present  is  that  attempts  to  produce  a 
curative  serum  have  failed,  while  a  serum  has  been  pro- 
duced by  the  hyperimmunization  of  a  horse,  by  means  of 
which  the  incubation  period  is  lengthened  and  the  attack 
rendered  milder  in  laboratory  animals,  though  relapses 
have  not  been  prevented. 

Treatment. — As  in  the  case  of  relapsing  fever,  there  is 
no  specific  for  tick  fever  and  the  treatment  must  therefore 
be  symptomatic.  It  should  be  on  the  same  lines  as  that 
indicated  for  relapsing  fever.  Atoxyl  and  mercury  have 
been  tried  recently  for  tick  fever,  but  without  effect. 

Prophylaxis. — As  far  as  we  know  the  disease  is  spread 
only  by  the  Ornithodorus  nioiibata  in  nature  (fig.  43). 
These  ticks  belong  to  the  division  Argasina,  and  these  differ 
from  the  ordinary  cattle  and  dog  ticks,  Ixodina,  in  that  the 
mouth  is  on  the  under  or  ventral  surface  of  the  body,  that 
there  are  no  dorsal  or  ventral  chitinous  plates  or  shields 
either  in  the  male  or  female,  that  the  last  joint  of  the  palpi 
is  quite  distinct  and  that  the  palpi  are  not  grooved  nor  do 


TICK    FEVER 


195 


Fig.   43. — Ornithodorus  savignyi.     a,  Ventral  aspect ;  d,  dorsal  aspect  ;  <■,  lateral 
aspect  between  second  and  third  pair  of  legs. 


196  TROPICAL   MEDICINE   AND   HYGIENE 

they  form  a  sheath  for  the  rostrum.  The  young  also  have 
four  pairs  of  legs  when  they  emerge  from  the  egg. 
In  habits  also  they  differ,  as  they  do  not  remain  firmly 
attached  to  their  host,  but  after  feeding  leave  him 
and  may  feed  on  many  individuals,  as  they  live  for 
months  or  years.  They  feed  at  night  mainly.  They 
inhabit  houses,  living  in  the  dry  dust  so  abundant  in 
houses  with  mud  floors,  or  in  thatch  or  reeds  of  which 
the  roof  and  walls  are  composed.  The  ticks  which  feed 
on  infected  persons  do  not  themselves  necessarily  become 
infective,  as  the  infection  is  transmitted  to  the  progeny, 
and  therefore  if  a  tick  feeds  on  an  infected  person  it  may 
be  many  months  before  the  progeny  of  these  ticks  can 
infect  a  susceptible  person.  Another  point  is  that  from 
an  infected  tick  many  infective  ticks  may  be  derived. 

The  problem  differs  therefore  in  many  important 
respects  from  prophylaxis  against  malaria.  Destruction 
of  these  ticks  may  be  attempted  but  is  difficult  to  carry 
out,  as  in  a  country  like  Africa,  where  termites  (white  ants) 
are  so  destructive,  wooden  floors  and  walls  are  imprac- 
ticable. Mud  floors,  reed  and  thatched  walls  and  roofs 
cannot  be  thoroughly  cleansed.  Even  in  European 
houses  as  little  woodwork  as  possible  is  used,  but  with 
cement  floor,  brick  walls  and  galvanized  iron  roofs  there 
is  little  danger  of  the  0.  inoubata  being  present. 

Prophylaxis  for  Europeans  is  fairly  easy.  In  travelling 
native  huts  should  be  avoided,  even  if  they  have  not  been 
occupied  for  many  months.  The  0.  niouhata  cannot 
climb  up  a  smooth  vertical  surface,  so  that  even  in  a 
native  hut  if  a  camp  bedstead  be  used  and  no  part  of  the 
bedding  be  in  contact  with  the  walls  little  risk  is  run. 
The  servants  must  be  instructed  not  to  place  the  bed- 
ding on  the  floor,  or  the  ticks  may  enter  it.  Bedding 
in  a  district  where  the  tick  is  common  should  always  be 
carried  in  a  tin  box.  These  ticks  do  not  readily  feed 
by  day  and  do  not  attach  themselves  to  persons  in 
movement,  therefore  there  is  little  risk  even  in  a  native 
hut  in  the  day  time,  or  at  night  whilst  the  hut  is  well 
lighted  and  the  occupant  is  awake. 


'I'ICK    FEVER 


197 


In  the  event  of  a  European  house  or  the  servants' 
quarters  becoming  infected,  careful  search  should  be 
made  for  the  ticks,  and  the  floors  and  walls  abundantly 
flushed  with  some  disinfectant  solution,  such  as  i  in  2,000 
perchloride  of  mercury  solution,  or,  and  better  in  the  case 
of  a  native-built  house,  it  should  be  pulled  down  and 
burned. 

Varieties. 

Some  authorities  consider  that  there  are  four  distinct 
varieties  of  relapsing  fever. 

Varieties  of  Relapsing  Fever  Contrasted.  —  European 
and  American  relapsing  fever  show  some  differences  and 
may  also  be  due  to  different  species  of  spirochaetes.  The 
more  important  differences  are  shown  in  this  table  : — 


Indian 

African 

European 

American 

Incubation  period... 

7  days 

5—7  days... 

5—7  days... 

5—7  days. 

Duration     of     first 

5—7  days... 

3  days, rarely 

3 — 6  days... 

5 — 6  days. 

attack 

up  to  5 

Duration     of     apy- 

5 — 13  days 

I — 8  days,  or 

7 — 10  days 

7 — 10  days. 

rexia 

more 

Number  of  relapses. . . 

I  in  40  per 
cent.,  more 
than  I  in  lo 
per  cent. 

3 — 5,  or  more 

1  —  2  days ... 

I,  rarely 
more. 

Relapses  absent  in . . . 

50  per  cent. 

? 

? 

? 

Jaundice     ... 

70 — 80  per 

Infrequent 

Mild,  except 

Mild,  except 

cent. 

in   grave 
cases 

in  grave 
cases. 

Eye  affections 

I  per  cent. 

Very  common 

Mentioned 

Mentioned. 

Mortality 

20 — 40    per 
cent. 

3 — 6  per  cent. 

Under  5  per 
cent. 

2 — 4  per  cent. 

Whilst  it  seems  clear  that  the  African  relapsing  fever 
is  even  clinically  a  distinct  disease  the  differences  between 
the  three  other  forms  are  less  marked.  As  regards  the 
parasites,  Mackie  proposes  to  call  that  in  Asiatic  relapsing 
fever  S.  carferi,  and  in  the  American  S.  novxi.  S.  obcr- 
ineieri  is  the  name  used  for   the  parasite   in   European 


"198 


TROPICAL   MEDICINE   AND   HYGIENE 


relapsing  fever  —  S.  recvirrentis,  is  more  correct  —  and 
S.  duttoni  in  the  African.  The  differences  in  the  para- 
sites are  shown  in  the  following  table : — 


S.  carie7'i 

S.  dtittoni 

S.  obermeieri 

S.  novyi 

Minimum    length 
Shape     ... 

12  jx 

Open  flexures 

13^ 

Open  flexures 

12  It. 
Spiral 

7— 9M- 
Regularly 

Animals    suscept- 

Monkeys; small 

Small  rodents 

Small  rodents 

spiral. 
Small  rodents 

ible 

rodents  with 
difficulty 

easily 

only    after 
passage 
through 

easily. 

Course  in  animals 

Very  mild     ... 

Very  severe 

monkeys 
Mild 

Severe. 

Serum  reaction  : — 

' 

Immune  serum 

no  effect  on 

S.  novyi 

S.  novyi  or 
S.       ober- 

S.     novyi 
and  S.  dut- 

S. obermeieri, 
S.     ditttoni, 

vieieri 

toni 

1    or  5".  carteri 

199 


CHAPTER  XVI. 

DISEASES   ASSOCIATED   WITH   SPIROCH/ET^ 
IN  THE  TISSUES. 

Syphilis  is  a  fairly  common  disease  in  most  tropical 
countries,  both  amongst  the  Europeans  and  the  natives. 
In  some  countries,  as  in  Central  Africa  and  some  of  the 
Pacific  Islands,  it  is  not  met  with  amongst  the  natives. 

Neither  race  nor  warm  climate  alone  have  any 
influence  on  the  manifestations  of  the  disease.  It  is 
indigenous  in  the  more  highly  civilized  countries,  such 
as  India  and  China,  and  has  been  carried  to  other  coun- 
tries chiefly  by  Arabs  and  other  traders,  including 
Europeans.  Travellers  are  apt  to  mistake  all  kinds  of 
ulceration  for  syphilis,  and  there  can  be  no  doubt  that 
much  exaggeration  as  to  the  frequency  and  violence  of 
the  disease  in  native  races  is  due  to  such  inaccuracies. 

Circumcized  races,  both  Mahommedans  and  others, 
are  quite  frequently  attacked,  but  in  them  a  considerable 
proportion  of  the  chancres  are  urethral.  The  primary 
sores  are  not  so  often  seen  in  natives  as  in  Europeans. 
These  are  frequently  extra-genital  or  within  the  rectum 
or  anus  as  the  result  of  sodomy,  or  on  the  abdomen  or 
pubes  or  scalp,  from  the  custom  among  certain  natives 
of  shaving  these  parts,  barbers  being  employed  ;  occasion- 
ally also  svphilitic  infection  follows  tattooing,  saliva  being 
largely  used  to  mix  the  pigments. 

Syphilitic  ulceration  among  native  races  in  the  Tropics 
is  apt  to  be  severe  or  even  phaged^enic  at  all  stages  of 
the  disease,  owing  to  neglect  of  both  cleanliness  and 
treatment.  This  is  less  common  amongst  prostitutes 
who  are  careful  as  to  personal  cleanliness,  e.g.,  Japanese, 
than  amongst  those  who  are  less  so,  e.g.,   Cantonese. 


200  TROPICAL  MEDICINE   AND   HYGIENE 

Secondary  symptoms  are  often  overlooked.  Macular 
eruptions  are  not  easily  seen  on  dark  skins,  and  as  there 
is  no  discomfort  attention  is  not  directed  to  them. 
Papular  eruptions  can  be  seen  more  readily.  The  throat 
conditions  if  severe  will  be  recognized,  but  are  not  often 
seen. 

There  is  a  prevalent  belief,  especially  among  soldiers, 
that  syphilis  contracted  from  natives  is  unusually  severe. 
This,  however,  is  not  borne  out  by  Indian  experience, 
where  the  disease  among  Europeans,  except  in  persons 
debilitated  by  other  causes,  appears,  if  anything,  milder 
than  at  home.  Among  the  native  army  in  India  the 
known  incidence  of  syphilis  is  much  less  than  among  the 
British  troops. 

Typical  tertiary  lesions  are  observed  and  include 
those  of  bone,  gummata  of  the  brain  and  abdominal 
viscera,  which  are  fairly  often  seen  in  post-niortefu 
examinations. 

On  the  whole  the  disease  is  less  severe  in  the  Tropics 
than  it  is  amongst  the  poorer  classes  in  England,  where 
the  treatment  has  been  neglected.  The  Chinese,  of 
course,  have  used  mercury  from  time  immemorial,  but 
other  races,  unless  treated  by  Europeans,  are  practically 
untreated. 

In  tropical  countries  where  yaws  is  uncommon  there 
is  no  tendency  for  the  syphilitic  eruptions  to  be  fram- 
boesial,  and  in  countries  where  yaws  is  common  the 
common  manifestations  of  secondary  and  tertiary  syphilis 
also  occur. 

Atheroma  and  lesions  of  the  vessels  are  fairly  common 
in  the  Tropics,  but  less  so  amongst  Indians  than  amongst 
the  negroes.  The  atheroma  is  frequently  in  patches  and 
often  leads  to  aneurism. 

It  must  be  remembered  that  a  chronic  irregular  fever 
occurs  in  some  cases  of  secondary  and  tertiary  syphilis 
and  may  be  mistaken  for  the  similar  fevers  that  occur  in 
tropical  diseases  such  as  kala-azar  or  malaria.  A  course 
of  antisyphilitic  treatment  may  speedily  cure  a  fever  of 
this  kind. 


DISEASES    ASSOCIATED    VVI'lll    SI'II>:OCH/KT.l':  201 

The  discuses  believed  to  be  remc^lely  due  lo  syphilis 
in  En^dund  ;ire  pnictically  unknown  in  1lic  Tropics 
amon^fst  the  natives;  these  are  the  parasyphilides — ,L;eii('ial 
paralysis  of  the  insane,  and  tabes  dorsalis. 

In  the  treatment  of  syphilis  amongst  natives  it  must  be 
remembered  that  mercury  is  not  well  borne  by  anaemic 
persons  and  that  pyorrhoea  alveolaris,  so  common  in  native 
races,  is  often  increased  by  mercury,  and  must  therefore 
be  treated  independently.  In  dealing  with  large  bodies 
of  men  intramuscular  injections  are  specially  valuable,  as 
a  weekly  injection  insures  sufficient  treatment. 

The  method  in  use  in  the  Army  is  essentially  that  intro- 
duced by  Colonel  Lambkin.  A  cream  is  made  of  metallic 
mercury  in  lanolin  : — 

Hydrargyri   ...  ...  ...  ...  ...  ...  ...     Ji. 

Adipis  lanre  ...  ...  ...  ...  ...  ...  ...     o''^'- 

Paraffin  liquid!  (with  2  per  cent,  carbolic  acid)   ...         ad     5X. 

The  mercury  and  lanolin  are  by  weight,  the  liquid  paraffin 
by  volume.  Great  care  must  be  taken  to  obtain  a 
thorough  mixture  of  the  mercury.  It  should  be  stored 
in  small  quantities,  as  if  kept  in  bulk  the  mercury  will 
settle  at  the  bottom.  Ten  minims  of  the  mixture  contain 
I  grain  of  mercury.  Injections  must  be  made  into  the 
muscle,  preferably  the  gluteus  maximus,  and  never  into 
the  subcutaneous  cellular  tissue.  The  skin  must  be  care- 
fully sterilized  before  the  injection.  An  all-glass  syringe 
should  be  used  ;  this  may  be  sterilized  by  drawing  up  olive 
oil  at  a  temperature  of  160°  F.  Between  the  injections 
the  point  of  the  needle  should  be  dipped  into  the  heated 
oil,  and  the  needle  should  be  wiped  with  a  sterilized 
cloth  so  that  none  of  the  mercury  cream  is  left  along  the 
track  of  the  needle. 

It  is  important  that  the  patient  should  not  take  any 
violent  exercise  for  some  hours  after  the  injection,  and 
care  must  be  taken  that  no  injection  is  given  in  a  place 
where  there  is  any  induration  as  a  result  of  previous 
injections.  The  advantages  of  the  method  are  :  (i)  An 
attendance  once  a  week  only  is  required  ;  (2)  there  is  no 


202  TROPICAL    MEDICINE   AND    HYGIENE 

uncertainty  as  to  whether  the  mercury  is  regularly  taken  ; 
(3)  though  the  rate  of  absorption  varies,  still  the  mercury 
is  certainly  absorbed.  The  disadvantage  is  that  the 
injection  is  slightly  painful,  that  a  certain  amount  of 
induration  and  tenderness  may  be  left,  and  that,  rarely, 
abscesses  may  form.  Much  depends  on  the  confidence 
the  natives  have  in  their  medical  ofBcer. 

Congenital  syphilis  is  not  common,  but  it  is  probable 
that  syphilis  is  an  important  factor  in  the  causation  of  the 
large  number  of  abortions  and  stillbirths,  and  is  respon- 
sible for  much  of  the  sterility  of  the  native.  It  must  be 
remembered  that  the  negro  is  fertile  earlier  in  life  when 
the  effects  of  the  virus  are  most  marked,  but  ceases  to  be 
fertile  in  many  cases  at  an  earlier  age  than  the  European, 
and  therefore  has  few  children  at  ages  when  the  most 
fatal  effects  of  the  disease  are  less  likely  to  occur. 

Prophylaxis. — Prophylactic  measures  are  similar  to 
those  required  in  England.  The  local  labour  supply 
is  usually  insufficient  for  the  large  plantations,  mines  and 
other  enterprises  of  Europeans.  Large  numbers  of  men 
are  therefore  imported  from  other  districts  and  countries 
or  attracted  by  the  superior  rate  of  pay.  Men  as  a  rule 
come  in  great  excess  of  women,  who  are  of  less  value 
as  labourers,  and  many  of  these  women  are  or  become 
prostitutes.  With  such  gangs  of  men,  whether  soldiers 
or  labourers  on  plantations,  it  is  often  possible  to  find 
the  infecting  agent  or  agents.  A  certain  proportion  of 
women  should  always  be  imported  with  the  men,  and 
this  is  arranged  for  in  Indian  immigration  ordinances. 
Every  encouragement  should  be  given  to  men  bringing 
their  wives,  and  labour  of  a  suitable  kind  should  be  pro- 
vided for  women  as  well  as  men,  even  if  it  is  not  directly 
remunerative  to  the  employer.  Under  any  circumstances 
the  immigrant  system  usually  results  in  a  larger  or 
smaller  proportion  of  the  men  becoming  infected,  and 
these,  having  earned  a  considerable  supply  of  money, 
often  disseminate  the  disease  on  their  return  to  their 
native  villages.      The  disease  is  then  propagated  in  the 


YAWS  203 

same  mannci-,  and  unless  the  human  canici-s  of  tlic  disease 
are  isolated  or  segregated  reliance  is  only  to  he  placed  on 
personal  prophylaxis. 

Regular  inspection  of  men  as  well  as  women,  detention 
and  treatment  until  the  most  infective  stage  is  passed, 
will  greatly  reduce  the  prevalence  of  the  disease. 

Legislation  and  increased  powers  in  dealing  with  such 
cases  are  much  to  be  desired. 

A  warning  is  necessary  to  missionaries  and  others  as 
to  interference  with  native  customs  too  quickly.  Amongst 
most  natives,  women  are  jealously  guarded  and  their 
movements  restricted  in  many  ways.  This  condition  is 
sometimes  considered  by  Europeans  as  "  slavery."  An 
unfortunate  result  of  too  speedy  liberation  from  their 
accustomed  restraints  is  a  great  increase  in  the  amount  of 
promiscuous  intercourse  and  the  rapid  spread  of  syphilis 
and  other  venereal  diseases. 

Other  Granulomata. 
Amongst  the  large  class  of  diseases  known  as  infective 
granulomata,  two  of  the  purely  tropical  ones  are  asso- 
ciated with  the  presence  of  spirochjeta,  yaws  and  granu- 
loma pudendi.  But  similar  organisms  have  been  found 
in  many  forms  of  ulcers. 

Yaws. 

Yaivs. — Franiboesia  tropica.  Native  names  :  Piirii 
(Malay),  Coko  (Fijian),  Paraiighi  (Ceylon),  &c.  This 
disease  is  characterized  by  the  appearance  of  successive 
crops  of  raised  granulomatous  nodules  covered  with  thin 
or  thick  sulphur-yellow  crusts  and  subsiding  without  deep 
ulceration  or  the  formation  of  any  but  superficial  scars. 
The  usual  duration  of  the  disease  is  two  or  three  years, 
but  on  the  parts  of  the  body  where  the  epidermis  is  thick, 
such  as  the  soles  of  the  feet,  it  may  persist  for  much 
longer.  Destructive  ulceration  of  the  mucous  surface  and 
a  lupoid  eruption  on  the  face  are  by  some  considered  to 
be  sequelae,  and  onychia  mav  also  occur, 

Geograpliical  Distribiifion. — As  an  indigenous  disease  it 


204 


TROPICAL   MEDICINE   AND    HYGIENE 


was  probably  limited  to  the  West  Coast  of  Africa,  to  the 
aborigines  of  the  Malay  Peninsula,  possibly  Ceylon,  and 
to  the  Pacific  Islands.  Introduced  by  the  slave:,  into 
the  West  Indies  and  South  America,  it  has  been  firmly 
established  there  for  over  a  century.  An  outbreak  has 
also  occurred  in  Assam,  probably  introduced  by  labourers 
returning  from  Fiji  or  the  West  Indies.  Cases  are  occa- 
sionally seen  in  many  tropical  ports,  and  to  a  limited 
extent  it  has  spread  amongst  the  inhabitants  of  such 
ports.  It  does  not  occur  on  the  East  Coast  of  Africa 
and  is  very  rare  in  the  central  plateau.  Outside  the 
Tropics  it  does  not  seem  to  spread. 


Fig.  44. 

Clinical  Course. — Experimental  inoculations  have  shown 
that  there  is  a  period  of  incubation  of  about  twenty-eight 
days.  In  such  experiments  there  need  be  no  primary 
sore ;  a  primary  yaw  is,  however,  common  in  accidental 
inoculation.  It  may  appear  at  the  edge  of  an  ulcer  or 
in  a  clean-cut  wound,  but  is  more  common  at  or  near 
the  junction  of  the  skin  and  mucous  membranes,  such 
as  the  angle  of  the  mouth.  When  there  is  a  primary 
sore   it   is   a  raised   granulomatous   mass    similar  to  the 


YAWS 


20  = 


siibsct|ucnt  eruptions.  Tlic  i^cnci'alizcd  eruption  iii;iy 
;ippe;u-  in  any  part  of  the  body  and  is  associated  with 
febrile  symptoms.  Sometimes  the  temperature  is  103' 
or  104°  F.  There  are  achin<4  pains  in  the  hmbs,  and 
particularly  in  tlie  back  and  loins,  sometimes  severe 
enougii  to  raise  the  suspicion  of  small-pox.  The  erup- 
tion may  be  abundant,  but  in  other  cases  there  may  only 


Fig.  45. 


be  a  few  yaws  limited  to  the  lower  part  of  the  face,  the  chest, 
or  the  genitals  (fig.  47).  When  there  are  few  yaws  they 
are  more  common  near  mucous  orifices  ;  when  abundant 
the  whole  body  and  limbs  may  be  involved  (tig.  45). 
On  the  extensor  surfaces  the  eruption  tends  to  be  more 
abundant.  The  scalp  and  axillae  are  rarelv  involved,  and 
the  palms  and  soles  only  in  the  later  eruptions.  The 
actual  duration  of  each  vaw  is  three  or  four  weeks,  and 


206 


TROPICAL   MEDICINE   AND    HYGIENE 


fresh   yaws   may   appear    before    the   subsidence    of   the 
earher  ones. 

On  moist  surfaces,  as  in  the  perinaeum  and  at  the  angles 
of  the  mouth,  httle  or  no  crust  is  formed  on  the  yaw, 
but  in   drier    parts  the  pecuHarly  yellow  scab  is  always 


FiG.    46. 


present.  This  scab  is  detached  with  difficulty,  and  a 
slightly  milky  fluid  is  found  beneath  it.  The  exposed 
surface  bleeds  very  readily.  The  glands  are  not  enlarged 
unless  the  yaw  is  injured  or  secondarily  ulcerated.  Ulcer- 
ation may  take  place  in  parts  exposed  to  much  movement 


LATE   YAWS  207 

or  to  friction,  and  secondary  deeper  ulceration  sometimes, 
but  rarely,  occurs. 

The  eruption  may  recur  for  two  or  three  years,  but 
the  later  crops  are  usually  scanty,  and  in  this  stage  are 
frequently  under  thick,  hardened  epideiinis,  such  as  the 
sole  of  the  foot  (fig.  46). 


Fig.  47. 


The  granulomata  in  such  situations  cannot  grow  to 
any  great  size,  and  are  compressed  by  the  thickened 
epidermis  and  very  painful.  These  painful  granulomata 
on  the  soles  of   the  feet  may  persist  for  years  after  all 


2o8  TROPICAL   MEDICINE   AND   HYGIENE 

other  manifestations  of  the  disease  have  ceased — "crab 
yaws." 

Sequelae  attributed  to  yaws  are  numerous,  but  the  evi- 
dence that  they  are  related  to  that  disease  is  inadequate. 
A  destructive  ulceration  of  the  mucous  membrane  of 
the  mouth,  palate,  pharynx,  and  nares  is  common  in 
Fiji,  and  occurs  in  other  countries  where  yaws  is  common. 
It  is  a  disease  which  occurs  usually  in  early  adult  life, 
many  years  after  the  last  definite  manifestation  of  yaws. 
It  occurs  in  persons  who  have  not  had  syphilis,  and  if 
not  a  sequela  of  yaws  is  probably  a  separate  and  distinct 
disease  and  will  be  described  separately.  Associated 
with  this  disease  is  sometimes  a  lupoid  ulceration  of  the 
skin  of  the  face,  extending  by  continuity  from  the  ulcera- 
tion of  the  nares.  Periostitis,  and  chronic  ulcers  of  the 
legs  and  elsewhere  have  been  described  as  sequelae  of 
yaws.  If  they  are  results  of  this  disease  they  are  very 
rare  ones.     Gummata  probably  do  not  occur. 

Diagnosis. — At  the  onset  of  the  general  eruption,  and 
whilst  the  granulomata  are  still  small,  in  cases  where  the 
muscular  and  back  pains  are  severe  and  the  temperature 
is  high,  the  disease  has  been  mistaken  for  small-pox  ;  such 
errors  are  very  rare.  The  disease  in  the  majority]  of 
cases  has  to  be  diagnosed  from  syphilis  and  other  skin 
diseases.  In  a  single  case  the  diagnosis  from  a  fram- 
boesial  syphilide  may  be  impossible  ;  from  any  other 
syphilide  it  is  easy.  The  absence  of  ulceration,  the  raised 
granulomatous  tumour  and  the  sulphur  crust  with  the 
milky  fluid  underneath  it  differentiate  the  disease  from 
rupia  or  similar  tertiary  syphilitic  lesions.  Where  the 
case  is  under  observation  the  close  similarity  of  the 
successive  eruptions  is  unlike  that  in  syphilis.  The 
exposure  to  contagion,  the  occurrence  of  other  cases, 
and  the  absence  of  any  other  signs  of  syphilis  all  aid 
in  the  diagnosis. 

Prognosis. — Death  may  occur  in  children  under  one 
year,  or  in  debilitated  persons,  but  even  in  such  cases 
a  fatal  termination  is  exceptional.     Good  feeding,  cleanli- 


YAWS    AND    SYl'HII.IS  209 

ncss,  and  protection  from  irritation  of  the  yaws  dinunish 
the  habihty  to  ulceration  but  do  not  shorten  the  course 
of  the  disease. 

Pathological  Anatomy. — The  lesions  are  limited  to  tlie 
skin  and  subcutaneous  tissues.  Essentially  the  i^rowth 
is  a  vascular  granuloma,  and  there  is  no  tendency  to 
caseation,  necrosis  or  suppuration.  The  epidermis  is 
softened,  and  the  distinction  between  the  various  layers 
is  lost.  Pigment  is  either  not  formed  or  irregularly 
distributed  in  the  deeper  layers  or  subcutaneous  tissue. 
Keratinization  is  imperfect  and  the  superficial  layers  of 
epidermis  are  cast  oiif,  and  form  the  scab  covering  the 
granuloma.  The  cause  of  the  peculiar  yellow  colour  is 
unknown.  In  moist  situations  in  the  neighbourhood  of 
the  genitals  or  mouth  there  is  little  or  no  scab  formation, 
and  superficial  ulceration  is  common. 

r7-(sa/;/;6'///.  —Probably  no  drug  influences  the  duration 
of  the  disease.  Mercury  and  arsenic  certainly  do  not. 
Potassium  iodide  is  uncertain  in  its  action.  The  erup- 
tions will  sometimes  disappear  rapidly  when  iodides  are 
given,  but  even  in  such  cases  when  the  use  of  the  drug 
is  continued  fresh  eruptions  appear.  The  use  of  iodides 
is  therefore  limited.  Local  applications  that  merely  sei-ve 
to  keep  the  granuloma  clean  are  valuable,  but  eschar- 
otics  and  irritants,  though  they  may  destroy  the  yaws 
are  likely  to  cause  the  formation  of  scars.  The  painful 
granulomata  on  the  feet  are  best  destroyed  by  the  action 
of  nitric  acid,  acid  nitrate  of  mercury,  or  silver  nitrate. 

Etiology.  —  Most  observers  who  have  had  extensive 
experience  of  the  disease  known  as  yaws  consider  it  to 
be  a  clinical  entity.  Some  eminent  authorities,  and 
especially  Hutchinson,  believe  it  to  be  syphilis,  and  that 
the  differences  from  the  common  manifestations  of  that 
protean  disease  as  seen  in  temperate  regions  are  due 
to  the  effect  of  climate,  race,  and  heredity  in  the  Tropics. 

The  similarity  of  the  two  diseases  will  be  admitted  by 
all.  In  both  there  is  a  rather  prolonged  period  of  incu- 
bation   with    a   primary   sore,  rarely   absent   in    syphilis, 

14 


■2IO  TROPICAL    MEDICINE    AND    HYGIENE 

commonly  absent  in  yaws,  and  a  series  of  cutaneous 
eruptions  lasting  for  months  or  years,  with  later  manifesta- 
tions usually  of  a  destructive  character,  which  are  common 
in  untreated  syphilis,  and  also  in  yaws  if  the  lupoid 
diseases  of  the  mucous  membrane  are  correctly  attributed 
to  the  antecedent  yaws.  The  parasitic  cause  of  syphilis 
is  now  generally  believed  to  be  a  spirochaete,  Spirochceta 
pallida,  and  a  spirochjete  morphologically  indistinguish- 
able from  S.  pallida  has  been  found  by  Castellani  in  yaws, 
S.  pertenuis.  That  the  diseases  belong  to  the  same  class 
is  clear ;  that  they  are  identical  is  a  different  matter,  and 
is  open  to  serious  question. 

The  manifestations  of  yaws  for  at  least  the  first  three 
years  of  the  disease  are  all  of  the  same  character,  the 
primary  sore  and  each  successive  eruption  differing 
slightly  in  moist  parts,  or  when  under  thickened  epi- 
dermis. Syphilitic  cutaneous  manifestations  are  poly- 
morphic. Yaws  may  be  universal  in  a  population,  but 
if  uninfected  newcomers  of  any  race — Europeans,  Portu- 
guese, Chinese,  Negro,  Malays,  Indians — are  introduced 
into  such  a  community  and  are  infected,  the  disease  they 
acquire  is  yaws,  and  resembles  in  all  its  characters  the 
disease  in  the  native  population.  From  a  single  source 
of  infection  in  a  negro  the  disease  has  been  acquired  in 
the  same  form  in  a  whole  family  of  Portuguese,  and  in 
an  Indian  servant.     Yaws  therefore  breeds  true. 

Syphilis,  when  acquired  by  members  of  the  same  races, 
presents  the  usual  characters  of  that  disease.  Syphilis  is 
little  modified  in  persons  resident  in  the  Tropics.  The 
formation  of  gummata  and  the  extensive  and  destructive 
bone  lesions  do  not  occur  in  yaws.  It  is  sometimes  urged 
by  those  with  little  experience  of  some  of  the  native  races, 
amongst  whom  the  disease  is  common,  that  the  over- 
crowding and  filth  of  the  native  houses  favours  the  wide 
diffusion  of  the  disease,  and  that  therefore  the  fact  that 
all  the  children  have  "  yaws  "  is  no  argument  against  the 
disease  being  syphilis.  A  closer  study  of  these  races  will 
convince  anyone  that  as  regards  personal  cleanliness  and 


YAWS    PKOl'lIYLAXIS  211 

absence  of  overcrowding  unci  morals  they  compare  very 
favourably  with  the  lower  classes  of  Europeans,  amongst 
whom  syphilis  does  not  become  universal  in  the  children. 

Yaws  does  not  protect  from  sypliilis  nor  syphilis  from 
yaws.  The  relationship  between  yaws  and  syphilis,  in  the 
sense  of  both  diseases  being  due  to  organisms  of  the 
same  genera,  is  admitted  and  was  predicted,  but  the 
relationship  is  like  that  between  variola  and  varicella,  not 
that  between  variola  and  vaccinia. 

Prophylaxis.  —  Infection  can  be  carried  from  man  to 
man  by  direct  contact,  and  the  virus  is  contained  in  the 
discharges  from  the  granulomata.  The  frequency  of  the 
early  yaw  in  the  neighbourhood  of  the  mouth  suggests 
that  food  is  a  frequent  source  of  infection.  The  com 
monest  ages  for  infection,  3  to  5  years,  are  ages  at  which 
children  frequently  exchange  partially  eaten  pieces  of 
food.  Probably  flies  are  also  direct  carriers  of  infected 
material,  and  the  frequency  with  which  ulcers  and 
wounds  become  infected  is  probably  explicable  in  this 
manner.  The  chigoe  {Sarcopsylla  penetrans)  is  by  some 
believed  to  be  an  important  carrier.  There  is  no  evi- 
dence that  the  virus  can  enter  through  the  unbroken 
skin,  but  cracks  about  the  mouth,  small  ulcers  as  a  result 
of  insect-bites,  or  other  sources  of  irritation  are  so 
common  in  the  Tropics  that  possibilities  of  infection  are 
numerous. 

There  is  little  risk  to  well-clad  Europeans,  even  if 
stopping  in  the  same  house  as  persons  with  the  disease, 
but  amongst  European  and  half-caste  children  who 
play  about  with  native  children  cases  of  infection  are 
common.  It  is  well  to  carefully  cover  up  even  superficial 
wounds,  and  to  prevent,  if  possible,  children  from  having 
access  to  natives  in  a  country  where  yaws  is  endemic, 
and  to  take  sufficient  precautions  to  prevent  the  inter- 
change of  partly  eaten  articles  of  food  with  native 
children. 

"  Guam  "  disease  in  most  respects  corresponds  to  the 
description  given  of  the  destructive  ulcerations  about  the 


212 


TROPICAL   MEDICINE   AND    HYGIENE 


naso-pharynx  so  common  in  Fiji,  and  there  considered  to 
be  tertiary  framboesia.  Those  who  consider  it  a  separate 
.disease  call  it  granuloma  gangrenosa.  It  is  said  to  be 
most  common  in  places  where  yaws  is  rare,  and  to  be  very 
rare  in  some  places  where  yaws  is  very  common.  Probr 
ably  it  is  the  same  condition  as  the  Fijian  "  kanailoma.'" 


FiG.    48. 


Granuloma  of  the  Pudenda. 

Serpiginous  Ulceration  of  the  Genitalia. 
(McLeod)  ;  Ulcerating  Granuloma  of  the  Puden- 
dum ;  Sclerosing  Granuloma  of  the  Pudenda. — 
The  disease  manifests  itself  as  a  chronic  indurated  super- 
licial  growth  on  or  near  the  genitalia,  male  or  female.  It 
is  slow  growing  and  extends  along  moist  surfaces,  whilst, 
the  older  and  deeper  portions  of  the  growth  are  converted, 
into  a  dense  fibrous  mass  of  tissue.     It  is  very  vascular. 

Geographical  Distribution. — It  occurs  in  many  islands 
of  the  West  Indies,  in  Tropical  South  America,  on  the 
West  Coast  of  Africa,   and  either  it  or  a  similar  disease 


GRANULOMA   OF   THE    PUDIiNDA 


213 


occurs    in    India,  Northern   Austi'alia,   and    many  oi    the 
Pacific  Islands. 

Clinical  Course.  —  This  differs  to  some  extent  in 
different  races,  and  in  the  two  sexes.  It  usually  commences 
in  the  male  on  the  penis,  and  extends  in  the  neighbourhood 
that  organ  ;  if  situated  on  the  skin  it  is  very  slow  growing, 
but  is  more  rapid  when  the  glans  is  attacked,  and  the 
granulations  may  then  be  very  large  and  coarse ;  it 
extends  for  a  fraction  of  an  inch  up  the  urethra,  and 
causes  very  serious  stricture.  It  rarely  extends  by  direct 
continuity  down  the  penis  ;  more  often  the  inguinal  folds 


Fig.  49. 

or  other  places  with  which  the  penis  may  rest  in  contact 
become  infected  (fig.  49),  and  from  such  a  point  extension 
by  continuity  along  the  fold  of  the  groin  (fig.  49),  and  back- 
wards on  the  inguino-scrotal  fold,  takes  place,  and  from 
that  directly  backwards  on  the  perineum  surrounding  the 
anus,  and  extending  up  it  into  the  lower  part  of  the 
rectum  (fig.  50).  Sometimes  both  groins  are  affected. 
Frequently  the  penis  and  scrotum  become  slightly  ele- 
phantoid,  probably  from  compression  of  the  lymphatics 
by  the  indurated  subjacent  tissue. 


214 


TROPICAL   MEDICINE   AND    HYGIENE 


In  the  female  the  early  growth  is  on  the  inner  surface 
of  the  labia  majora  or  nymphse,  which  may  become 
elephantoid,  and  the  growth  extends  upwards  into  the 
vagina,  and  rarely  into  the  bladder.  It  also  extends  over 
the  labia  majora,  and  backwards  along  the  perineum, 
surrounding  and  extending  up  the  anus.  In  such  cases, 
where  both  the  vagina  and  rectum  are  involved,  incurable 


Fig.  50. 

recto-vaginal  fistulas  are  common.  The  growth  may 
continue  for  many  years,  and  the  general  health  of  the 
patient  is  not  affected.  The  lymphatic  glands  are  not  en- 
larged, though  there  is  evidence  of  lymphatic  obstruction. 
There  is  always  a  considerable  formation  of  hard  fibrous 
tissue    beneath   the    growth,    and   when    healing    occurs 


GRANULOMA  OK  THK  PUDKNDA         215 

natui'.'illy  the  growth  is  entirely  converted  into  dense 
fibrous  tissue.  Very  rarely  complete  cicatrization  takes 
place ;  more  frequently  it  is  partial  and  extension  of  the 
growth  at  the  edges  takes  place.  Spontaneous  healing 
of  the  mucous  surfaces  does  not  take  place. 

The  diagnosis  has  to  be  made  from  other  diseases  of 
the  same  part.  On  the  penis  it  is  frequently  mistaken 
for  epithelioma.  In  the  groin  it  may  be  mistaken  for  any 
form  of  ulceration,  syphilitic  or  otherwise.  In  the  vagina 
it  is  usually  mistaken  for  chronic  gonorrhoea.  The 
chronicity  of  the  growth,  the  dense  fibrous  base,  and  the 
absence  of  glandular  enlargement  are  important  points 
in  the  diagnosis.  In  cases  of  doubt,  microscopic 
examination   will    exclude   epithelioma. 

Prognosis  as  regards  life  is  good.  The  growth  is  not 
malignant.  Natural  cure  is  highly  exceptional,  and  it 
is  only  when  complete  removal  of  the  growth  can  be 
effected  that  recovery  is  probable. 

The  most  troublesome  complications  are  stricture  of 
the  meatus  of  the  urethra,  which  can  only  be  treated 
effectually  by  amputation  of  the  glans  penis  ;  recto-vaginal 
fistulas,  which  are  not  suited  for  operations,  as  the  tissue 
between  the  rectum  and  vagina  is  mainly  composed  of 
the  growth  ;  and  stricture  of  the  anus  with  ulceration 
of  the  lower  part  of  the  rectum.  If  the  growth  does  not 
extend  too  high,  excision,  of  the  rectum  gives  good  results 
in  the  last  complication. 

Pathological  Anatomy.  —  The  growth  is  a  vascular 
granuloma.  The  cells  are  round  cells  with  a  single 
rounded  nucleus.  There  are  no  giant  cells.  There  is 
no  tendency  to  caseation,  necrosis,  or  suppuration,  and 
the  epithelium  is  usually  present  over  the  growth,  though 
softened  and  thickened. 

Treatment.  —  Mercury  and  potassium  iodide  in  the 
majority  of  cases  have  no  effect.  In  a  few,  where  the 
tendency  to  natural  cure  is  strong,  large  doses  of  iodides 
seem  to  aid  this  tendency. 

Cleanliness  and  antiseptic  dressing  favour  rather  than 


2l6  TROPICAL   MEDICINE   AND   HYGIENE 

retard  the  growth.  Escharotics,  such  as  chloride  of  zinc, 
nitrate  of  mercury,  and  saHcyhc  acid,  are  rarely  effective  ; 
complete  excision  of  the  growth  where  that  is  possible 
is  highly  satisfactory,  but  the  dense  fibrous  tissue  should 
be  excised  as  well.  The  raw  surface  left  is  always  more 
extensive  than  the  growth  removed.  Where  excision  is 
impossible,  scraping  and  the  use  of  escharotics  may  give 
satisfactory  results. 

Good  results  have  been  obtained  by  the  use  of  the 
Rontgen  rays.  In  Dr.  McLeod's  case  the  use  of  these 
rays  converted  the  granulomatous  tissue  into  a  cheesy 
mass,  which  was  readily  scraped  away,  and  healing  then 
took  place  rapidly. 

Etiology.  —  The  occurrence  on  the  genitalia  and  the 
different  situations  in  the  two  sexes  are  strongly  in  favour 
of  the  view  that  the  disease  is  conveyed  by  venereal  inter- 
course ;  it  does  not  seem  to  be  highly  contagious,  as  there 
are  cases  where  the  husband  only  is  infected  and  the 
wife  escapes. 

Spirochcetes  resembling  S.  pallida  and  S.  refringens  have 
been  described  by  Wise  as  occurring  in  these  granulomata. 


217 


CHAPTER    XVII. 

Intestinal  Protozoa,  &c. 

Many  protozoa  are  found  in  the  intestines,  and  may 
be  discharged  with  the  faeces.  In  coccidia  infections 
either  of  the  Hver  or  intestinal  mucosa  the  fertihzed 
macrogametes  are  discharged  in  this  manner. 

The  more  important  of  the  human  intestinal  protozoa 
are  those  associated  with  diarrhoea  and  dysentery.  These 
diseases  are  so  often  due  to  bacterial  infections,  and  the 
prevention  of  such  diseases  so  closely  connected  with  the 
disposal  of  sewage  and  the  provision  of  a  good  water 
supply,  that  they  are  best  considered  at  the  same  time  as 
the  similar  diseases  due  to  vegetable  organisms  in  Part  III. 
Only  a  brief  reference  to  these  parasites  and  the  diseases 
they  cause  will  be  given  here. 

The  protozoal  organisms  described  as  concerned  in 
the  production  of  intestinal  diseases  are  Sarcodina,  such 
the  Ainceba  coli ;  Flagellata,  as  Tricliomojias  hoiiiinis, 
Lamblia  intestinaUs  and  various  spirochseta;  and  Infusoria 
(Ciliata),  as  the  Balantidiiun  coli  (fig.  51).  Of  these  the 
most  important  is  the  Anuxba  coli — Ent ainceba  histolytica 
(Schaudinn). 

Other  protozoa,  especially  Bahmtidiiim  coli,  which 
invades  the  tissues,  may  cause  ulceration  and  all  the 
symptoms  of  dysentery. 

Lamblia  intestinaUs  is  probably  pathogenic.  It  does 
not  invade  the  tissues,  but  lies  closelv  applied  bv  its 
sucker-like  aspect  to  the  mucosa,  both  in  the  small  and 
large  intestine,  and  is  associated  with  chronic  enteritis. 

The  symptoms  are  of  a  chronic  recurrent  diarrhoea, 
with  abundant  discharge  of  mucus,  often  bile-stained,  and 
sometimes  there  is  also  blood.     When  there  is  diarrhcea 


2l! 


TROPICAL   MEDICINE   AND    HYGIENE 


the  parasite  may  be  found  in  abundance ;  at  other  times 
the  encysted  forms  only  will  be  found.  These  are 
easily  recognized  by  their  oval  shape  and  the  pair  of 
nuclei  situated  near  one  extremity.  The  treatment  is  not 
very  satisfactory.  Free  purgation  to  remove  the  mucus, 
followed  by  intestinal  antiseptics  such  as  kerol,  seems  the 
most  promising  line  of  treatment. 

The  Amoebina. — An  order  belonging  to  the  Rhizopoda 


Fig.  si. 


or  Sarcodina.  The  members  of  this  order  are  either  naked 
masses  of  protoplasm  or  enclosed  in  a  simple  shell,  either 
secreted  by  the  organism  or  formed  from  some  foreign 
substance.  They  have  blunt,  lobulated  or  finger-shaped 
pseudopodia  and  a  single  nucleus.  Many  of  them  live 
in  fresh  or  salt  water,  and  are  abundant  where  there  is 
moist  decaying  vegetation  ;  some  are  parasitic.  In  the 
genus  Amoeba  the  body  is  always  naked,  and  usually  there 
is  a  marked  distinction  between  the  outer  part,  ectosarc, 
and   the   interior,    endosarc.      The   former   is    clear  and 


INTESTINAL   PROTOZOA,   AMGiHA 


219 


tninsparcnt  but  viscid,  whilst  the  latter  is  more  liquid 
and  granular,  and  frequently  contains  foi-eign  bodies 
taken  in  as  food.  The  compact  nucleus  and  a  contractile 
vesicle  are  contained  in  the  endosarc. 


Asexual  multiplication  by  simple  division  of  nucleus  and  cytoplasm. 


Fig.  52. — Scheme  of  Development  of  Amreba.  Multiplication  in  encysted 
forms  (autogamous).  ?  sexual  multiplication.  The  early  stages  of  division  of 
the  nucleus  [a—d)  and  conjugation  of  the  divided  nuclei  in  pairs  (e),  followed 
by  further  division  of  these  products  of  conjugation,  first  into  two  and  then 
into  four  each  {/—z).  The  thick  wall  of  the  cyst  in  the  later  stages  indicates 
the  hardening  of  the  cyst  wall  during  the  stages  when  the  cysts  are  outside 
the  body. 


When  active  the  amcebas  are  constantly  changing  shape, 
and  throw  out  blunt  processes  or  pseudopodia.  The 
number  and  shape  of  these  are  points  to  consider  in  the 
differentiation  of  species.  When  motionless  or  dead  the 
amoebae  assume   a   spherical  form,  and   are    difficult   to 


220  TROPICAL   MEDICINE    AND    HYGIENE 

distinguish  from  other  mononuclear  cells.  Propagation 
takes  place  by  budding,  division,  or  segmentation. 

Amoeba  coli. — This  is  a  large  amoeba,  frequently  '05  mm. 
in  diameter,  though  smaller  forms  are  common.  The 
ectosarc  can  be  readily  seen  when  pseudopodia  are 
thrown  out,  but  it  is  difficult  to  see  in  the  resting  animal. 
The  pseudopodia  are  very  broad  and  only  one  or  two 
are  protruded  at  a  time.  Movement  is  active  at  or  near 
blood-heat,  but  is  retarded  or  stopped  at  lower  tempera- 
tures. Multiplication  of  the  amoeba  may  take  place  by 
simple  division  ;  the  nucleus  divides,  and  the  protoplasm 
then  divides  so  that  two  equal  individuals  are  produced. 
This  is  the  asexual  method  of  reproduction,  and  takes 
place  readily  where  the  conditions  for  existence  are 
favourable.  The  second  method  may  be  considered  as 
a  rudimentary  sexual  process,  though  the  conjugation  is 
by  fusion  of  two  chromatin  masses  derived  from  one 
nucleus  and  not  of  two  separate  cells. 

If  considered  as  a  sexual  process  it  would  be  an  instance 
of  autogamy.  In  this  method  the  amoeba  becomes 
encysted.  The  nucleus  divides  into  two,  and  each  of 
these  nuclei  after  extruding  polar  bodies  again  divides 
into  two.  The  four  nuclei  thus  produced  conjugate  in 
pairs,  so  that  the  number  of  nuclei  is  again  reduced  to 
two.  These  two  nuclei  each  divide  into  two  and  then 
again  divide  so  that  there  are  eight  nuclei,  and  these  with 
the  protoplasm  segmented  round  them  form  eight  young 
amoebae  which  are  still  contained  in  the  cyst  (fig.  52). 
These  quasi-sexual  encysted  forms  are  resistant,  and  it  is 
probably  in  this  form  only  that  is  capable  in  the  para- 
sitic amoebaj  of  retaining  vitality  in  a  free  form  under 
ordinary  meteorological  conditions. 

These  encysted  forms  are  therefore  the  important  ones, 
as  the  infective  agents  in  amoebic  infection.  In  some 
of  the  parasitic  amoebae  in  the  lower  animals  the  active 
amoebae  are  only  found  in  the  small  intestine.  The 
changes  described  take  place  in  the  large  intestine.  The 
amoebae  passed  in  the  faeces  are  all  encysted.     In  such 


INTESTINAL    PROTOZOA,    AMOCIiA  221 

animals,  if  the  intestinal  contents  were  passed  rapidly 
through  the  alimentary  canal,  as  aftei"  purgatives  (;r  in 
diarrhoea,  active  amoebae  will  be  passed  with  the  stool. 

In  man  encysted  amcebcX3  may  be  found  in  apparently 
healthy  stools,  but  the  hosts  from  time  to  time  have  attacks 
of  diarrhoea  or  dysentery  and  then  the  active  amo^hcc  are 
present  in  the  stools. 

AmcEb?e  parasitic  in  the  internal  organs  of  man  are 
sometimes  called  Eiitanicebcv.  Morphologically  there  is 
no  real  diiference  between  these  and  other  amoebae 
beyond  the  absence  of  a  contractile  vesicle. 

There  are  said  to  be  three  species,  one  occurring  in  the 
mouth,  A.  hnccalis,  in  some  persons  with  dental  disease, 
and  two  in  the  large  intestine.  One  of  these,  the  A.  coli, 
or  Entanioeha  coli,  is  not  found  in  other  parts  of  the 
body  and  the  life-cycle  is  as  described  by  Schaudinn. 
According  to  the  same  author  it  is  distinguishable  by  its 
appearance  as  the  ectosarc  or  ectoplasm,  is  not  visible  as  a 
distinct  layer,  and  the  nucleus  is  large  and  rich  in 
chromatin,  so  that  it  stains  deeply  in  stained  preparations. 
This  amoeba  is  not  considered  to  cause  disease.  It  may  be 
present  in  the  small  intestines  as  an  active  motile  amoeba, 
and  only  the  encysted  forms  found  in  the  stools  unless 
there  is  diarrhoea. 

The  other  intestinal  amoeba,  Entmnoeha  histolytica,  has 
a  more  distinct  ectoplasm  and  the  pseudopodia  are 
entirely  formed  by  it  at  first,  so  that  they  are  tougher  and 
stronger  than  those  of  the  A.  coli.  The  nucleus  is  not 
readily  visible  and  is  poor  in  chromatin,  and  therefore 
does  not  stain  deeply  in  stained  preparations.  Schaudinn 
describes  the  multiplication  as  different  from  the  E.  coli. 

The  whole  cell  does  not  form  a  cyst,  but  a  series  of 
buds  are  formed  externally,  each  of  which  becomes  a 
latent  encysted  form.  These  observations  have  not  been 
confirmed,  and  by  many  the  distinctions  between  E.  coli 
E.  histolytica  are  doubted. 

The  E.  histolytica  may  enter  the  subcutaneous  tissues 
and    be    carried    to     various    Darts    of    the    body,    such 


222  TROPICAL    MEDICINE   AND    HYGIENE 

as  the  liver,  spleen,  and  kidneys,  and  there  cause  the 
formation  of  abscesses.  These  abscesses  are  slowly 
formed  and  may  attain  enormous  size,  containing  many 
pints  of  pus.  They  are  usually  single,  but  two  or  three 
are  not  rare.  The  pus  in  such  abscesses  is  white,  yellow, 
or  may  be  chocolate  in  colour.  It  is  a  very  thick,  slimy 
pus.  The  walls  of  the  abscess  are  rugged,  and  as  a  rule 
there  is  little  formation  of  fibrous  tissue  around,  though 
there  is  an  area  of  intense  congestion.  In  the  pus  from 
such  an  abscess  no  bacteria  are  found,  either  on  examina- 
tion or  by  culture,  in  the  majority  of  cases.  In  others, 
the  minority,  there  are  bacteria,  but  these  are  not  of  any 
uniform  species.  This  fact  is  taken  to  show  that  the 
amoebae  are  pyogenic,  and  that  for  the  formation  of  pus 
no  bacterial  aid  is  necessary.  Others  particularly  state 
that  in  early  abscesses  bacteria  are  to  be  found,  but  admit 
the  possibility  that  they  have  been  carried  by  the  amoebae, 
and  that  in  the  large  sterile  abscesses  these  bacteria  have 
died  out. 

The  amoebae  are  very  scanty  in  the  pus  in  the  abscess, 
so  that  they  are  rarely  to  be  found.  In  the  walls  of  the 
abscess,  in  scrapings  from  the  walls,  and  in  the  pus  dis- 
charged a  few  days  after  the  abscess  is  opened,  they  are 
usually  present  in  very  large  numbers.  An  abscess  may 
become  quiescent  and  encapsuled  or  be  reduced  to  a 
putty-like  mass.  More  commonly  they  continue  to 
increase  in  size,  and  bursting  through  the  liver  may  extend 
in  the  cellular  spaces  almost  anywhere.  Frequently  they 
burst  into  the  lungs  or  intestines  and  a  natural  cure 
results. 

The  treatment  and  symptomatology  of  hepatic  abscess 
will  be  more  fully  considered  with  other  forms  of 
hepatitis  and  with  dysentery  (vol.  iii.).  Ipecacuanha  is 
again  coming  into  favour  in  cases  of  amoebic  hepatitis 
when  there  is  no  evidence  of  the  formation  of  pus. 

A.  coll  die  if  left  in  the  faeces  as  soon  as  putrefaction 
occurs.  Reproduction  takes  place  by  simple  division 
whilst  they  are  parasitic,  but  transference  from  one  host 


HEPATIC   AliSCKSS 


223 


to  another  is  believed  to  be  by  the  encysted  forms.  In 
these  the  organism  becomes  spherical,  is  covered  with  a 
thickened  cyst  wall,  and  the  contents  divided.  Amoebic 
dysentery  will  be  fully  considered  later,  with  otiier  forms 
of  that  disease.  Here  it  is  sufficient  to  state  that  the 
disease  may  be  acute,  and  rapidly  fatal  perforation  in  this 
form  in  the  most  severe  cases  is  not  uncommon. 

In  the  common  form  the  onset  may  be  sudden,  but 
more  frequently  is  insidious,  sometimes  the  patient  is  not 
even  laid  up.  It  runs  a  very  protracted  course  :  attacks  of 
diarrhoea  with  the  passage  of  a  little  mucus  and  blood, 
alternating  with  periods  of  constipation,  when  the  hard 
fasces  are  sometimes  coated  with  blood  or  mucus,  or  the 


TIME 

A.M. 

P.M. 

A.M. 

P.M 

A.M 

P.M. 

A.M. 

P.M. 

A.M. 

P.M. 

A.M. 

P.M. 

A.M. 

P.M. 

104- 

103 

1  02 

1  0  1 

1  00 

99 

98 

97 

>. 

\ 

1\ 

K 

\ 

N 

\, 

N 

/ 

\ 

\ 

p 

>i\ 

b 

f 

1a 

/ 

A 

J 

\ 

^ 

V 

\    1 

\r 

J 

v^ 

,/ 

A 

sl 

1 

\ 

^1 

J 

y 

J 

V 

Fig.   53. — Hepatic  abscess. 

stool  may  be  apparently  normal.  This  relapsing,  or  rather 
remittent,  type  of  dysentery,  for  the  stools  are  rarely 
normal,  is  usually  associated  with  the  amoeba  indistin- 
guishable from  A.  colt  or  E,  histolytica.  Associated  with 
this  type  of  dysentery  is  hepatic  abscess,  and  rarely 
abscesses  in  other  organs,  such  as  the  spleen.  These 
abscesses  are  usually  sterile  as  regards  bacterial  growth,  but 
in  the  walls  of  the  abscesses  the  amoebje  will  be  found 
in  abundance.  The  possibility  of  this  condition  must 
always  be  considered  in  any  person  who  has  had  chronic 
dysentery,  however  mild,  and  in  any  person  from  the 
Tropics  with  a  chronic  irregular  fever  (fig.  53).  There 
is  nothing  characteristic  about  the  temperature  and  there 


224  TROPICAL   MEDICINE   AND    HYGIENE 

may  be  periods  of  apyrexia.  The  liver  is  enlarged  and 
often  tender,  but  the  enlargement  is  not  always  marked. 
Leucocytosis  occurs,  but  may  be  slight,  and  is  often  only 
to  the  extent  of  12,000  to  15,000  leucocytes.  The  poly- 
morphonuclear cells  form  75  to  80  per  cent,  of  the  total, 
as  a  rule. 

In  hepatic  abscess  of  this  kind  there  may  be  two  or 
more  abscesses,  but  usually  there  is  only  one.  Solitary 
hepatic  abscess  may  occur  in  England,  and  in  the  Tropics, 
and  may  be  due  to  other  causes,  e.g.,  Ascaris  hunbricoides 
and  Clonorchis  sinensis.  When  due  to  amoebae  the 
associated  dysentery  may  be  very  mild  and  in  many  cases 
no  history  of  dysentery  can  be  obtained,  but  in  these 
either  amoebse  are  found  in  the  stools  or  ulceration  of  the 
caecum  is  found  at  the  post-mortem  examination. 

In  some  countries  where  hepatic  abscess  is  said  to  be 
rare,  as  in  the  West  Indies,  at  post-mortem  examinations 
it  is  found  to  be  common  ;  clinically,  the  condition  is 
often  overlooked. 


225 


APPENDIX. 

I. — Notable  Dates. 

Malaria. — Discovery  of  the  parasites,  Laveran,  November  6, 
1880.— Differentiation  of  species  and  asexual  life-cycle,  Golgi 
and  others,  autumn  of  1885,  and  onwards.  — Conjugation  of 
sexual  forms,  McAllum,  1897-8.— Sexual  cycle,  Ross,  1897-8. 

Redwaier  Fever. — Piroplasma  discovered  by  Babes  in  1888. — 
Mode  of  transmission.  Smith  and  Kilburne,  1893. — Mode  of 
transmission  of  yellow  fever,  Reed  and  Carroll,  U.S.  Army 
Commission,   igoo-i. 

Trypanosomes. — In  fish,  Valentine,  1841. — In  frogs,  Gruby, 
1843. — In  rats,  Lewis,  1878.  As  a  cause  of  disease  (Surra), 
Evans,  1880. — As  a  cause  of  disease  (Nagana),  Bruce,  1894. — 
In  man,  Nepveu  described  a  trypanosome,  1890. — In  man 
Ford  discovered  and  Dutton  described  T.  gamhiense,  1901. — 
In  man,  in  sleeping  sickness,  Castellani  discovered  the  same 
trypanosome  in  the  cerebro-spinal  fluid,  1902. 

Spirochcsta  obermeieri  or  Spirochata  recmventis,  discovered  by 
■Obermeier,  1873,  named  S.  recurrentis ,  1874,  and  5.  obermeieri, 

1875. 

SpirochiBta  duttoni. — P.  Ross,  1904. 

SpirochcBta  pallidum  or  Treponema  pallidum.  —  Schaudinn, 
spring  of  1905.  Spirochata pertcnnis. — Castellani,  June,  1905. — 
Spirochseta  in  granuloma  pudendi.  Wise,  1906. 

Leishman-Donovan  Bodies. — Leishman  and  Donovan  indepen- 
dently in  kala-azar,  1900. — In  Delhi  boil,  Wright,  1903. — 
Rogers  proved  their  flagellate  stage,  1904. 

Amoeba  coli  first  found  in  stool  by  Lambl,  i860,  and 
recognized  as  the  cause  of  dysentery  by  Losch,  1875. — 
Trichomonas,  Donne,  1836. — Lamblia  intestinalis ,  Lambl,  1859. 
— Balantidium  coli,  Malmsten,  1857,  recognized  as  a  cause  of 
dysentery  by  Strong  and  Musgrave,  1902. 

This  list,  though  giving  the  names  of  the  actual  discoverers 
and  the  dates,  does  not  necessarily  imply  that  the  only  or  even 
the  main  credit  is  due  to  the  actual  discoverers. 

15 


226  TROPICAL    MEDICINE    AND    HYGIENE 

Most  discoveries  are  founded  on  antecedent  ones ;  the  part 
played  by  mosquitoes  in  carrying  malaria  is  based  on  the 
previous  observations  of  Manson  on  the  transmission  of  filaria. 

Improvement  in  methods  of  technique  leads  directly  to 
further  discoveries,  and  the  introduction  of  a  simple  rapid 
method  of  staining  for  chromatin  by  Leishman  led  to  the 
discovery  of  the  Leishman-Donovan  bodies  and  their  relation- 
ship to  flagellates.  Irl  other  cases,  discoveries  have  been 
made  independently  by  two  or  more  workers  nearly  at  the 
same  time.  The  SpirochcBta  diittoni  was  discovered  indepen- 
dently by  Dutton  and  Todd  very  shortly  after  P.  Ross. 

In  trypanosomiasis,  though  Castellani  discovered  the  para- 
site in  cases  of  sleeping  sickness,  the  fuller  confirmation  of 
the  causal  connection  and  the  mode  of  transmission  is  mainly 
due  to  Bruce  and  others.  It  is  rare  to  find  that  the  credit  of 
any  discovery  is  due  to  one  man  only. 

Nor  can  the  influence  of  the  English  Tropical  Schools^ 
founded  in  iSgg,  be  ignored,  nor  their  founders,  including  Sir 
Patrick  Manson,  Mr.  J.  Chamberlain   and  Sir  Alfred  Jones, 

II. — Important  Measurements. 
I  ^(micron)         ...     =  o'ooi   millimetre  or  sy-Joo  °^  ^^  inch 

nearly. 
I  millimetre         ...     =  0*04  or  Jg- ^'^*^-^' 
25  millimetres       ...     =1  inch. 
I  centimetre         ...     =  0-39  of  an  inch. 
I  gramme  ...     =  15*432  grains. 

28  grammes  ...     =1  ounce,  nearly. 

I  cubic  centimetre     —  16-23    minims,    and    weighs    at  4°  C. 

I  gramme. 
28  cubic  centimetres    =  i  ounce  nearly. 
I  litre       ...  ...     =  i|  pints  or  35  ounces,  nearly. 

Normal  blood  :    Weight  about  J§-  of  the  body  weight,  say,. 
9  pints  or  5,000  cubic  centimetres. 
Red  corpuscles  :  About  5,000,000  per  cubic  millimetre. 
Leucocytes  :   6,000  to  8,000  per  cubic  millimetre. 
Of  these  65  to  75  per  cent,  are  polymorphonuclear  leucocytes. 
,,  5   ,,   10  ,,  ,,    large  mononuclear. 

,,        15  ,,  25         ,,         ,,    lymphocytes,      but       number 

varies     according     to    the 
stage  of  digestion. 
,,  I   ,,     3         ,,  ,,    eosinophiles. 


APPENDIX 

22 

Malaria  diameter  of 

"  spores " 

or 

merozoites : — 

Benign  tertian 

•••     1-5  M- 

Quartan  ... 

...     175^. 

Subtertian 

...     07  M. 

Full-grown  parasite, 

sporocyte 

or 

schizont  : — 

Benign  tertian 

...     8-5  M. 

Quartan  ... 

...     6^. 

Subtertian 

... 

...     4-5^. 

Full-grown  zygote 

-=    50  to  60  fx. 

Sporozoite 

-     HA'. 

Leishman-Donovan 

body     ... 

=    2-5  to  3-5  M  X 

['5  to  2  ^ 

A  mceha  coli 

...   Up  to  50  M. 

Encysted  form 

... 

...     15  to  20  fx. 

Lamhlia  intcstinalis 

...    Up  to  15  M  in 

length. 

Encysted  form 

...    13  M  X  7m. 

Trichomonas  hominus 

...  3  M  to  20  M. 

Encysted  form 

... 

-  .   Up  to  15  fx. 

III. — Classific.*lTion  of  Diptera. 


Suborder  I.  OrthorrhapJia. — The  adult  imago  escapes  from 
the  pupal  case  through  a  longitudinal  anterior  or 
posterior  T-shaped  slit.  As  there  is  no  ptilinum 
there  is  in  the  imago  no  frontal  lunule.  Antennae 
usually  project  in  front  of  the  head. 
They  are  divided  into  Nematocera  (thread-like  antennae) 
and  Brachycera  (short  antennae). 
Nematocera. — Antennae  have  many  joints  —  always 
more  than  six ;  the  segments,  except  the  one  at 
the  base,  are  similar  to  each  other ;  palps,  usually 
four  or  five  joints. 

Nematocera  vera. — Joints  of  the  antenna  are  long, 
and  frequently  have  whorls  of  hairs,  legs  long 
and  slender,  abdomen  usually  long,  e.g.,  Culicidae 
(mosquitoes). 

Nematocera  anomala. — Antennae  composed  of  many 
segments ;  but  these  are  all  short,  and,  as  a  rule, 
without  whorls  of  hair.  The  abdomen  is  usually 
stout,  and  the  legs  are  shorter  and  thicker  than 
in  N.  vera,  e.g.,  Simulidse,  or  sand-flies. 


228      ,  TROPICAL   MEDICINE   AND    HYGIENE 

Brachycera. — The  number  of  true  joints  in  the  an- 
tennae is  less  than  six  ;  palps,  one  or  two  joints. 
Brachycera  vera. — Third  joint  of  antennae  is  not  ringed, 
and  usually  terminates  in  a  bristle  or  style,  e.g., 
Asilidae,  or  robber-flies. 
Brachycera  anomala. — Terminal  joint  of  antennae  com- 
posed of  several  short  segments  fused  together. 
These  fused  segments  appear  as  rings,  e.g., 
Tabanidae. 

Suborder  II.  Cyclorrhapha. — A  circular  cap  is  pushed  off  the 
pupal  case  by  the  bladder-like  protrusion,  ptilinum, 
which  forms  on  the  anterior  part  of  the  head,  and 
the  imago  escapes  through  the  circular  opening 
thus  made. 
In  the  imago  a  curved  scar  is  left  when  the  ptilinum 
contracts.  This  scar  is  the  lunule,  and  the  presence 
of  this  scar  shows  that  the  insect  belongs  to  the 
Cyclorrhapha.  Antennae  are  short,  usually  three- 
jointed,  and  more  or  less  flattened  against  the  head 
or  dependent.  The  third  segment  has  at  the  base 
a  bristle  or  style,  arista. 
(i)  AscHizA. — The  extremities  of  the  lunule  are  not 
continued  as  sutures  on  each  side  of  the  face, 
e.g.,  Syrphidae,  or  hover-flies. 
(2)  ScHizoPHORA. — The  extremities  of  the  lunule  are 
continued  as  lines  on  each  side  of  the  face,  so 
as  to  separate  off  the  antennae  and  mouth-parts 
from  the  rest  of  the  face.  These  lines  form  the 
frontal  suture,  e.g.,  Muscids,  Glossinas,  Stomoxys. 

Suborder  III.  Pupipava. — Larva  nourished  within  the  parent 
and  changed  into  a  pupa  without  feeding.  Some 
are  wingless,  in  others  the  wing  venation  is  im- 
perfect. Antennae  are  small  rounded  masses  show- 
ing no  division  into  joints,  with  one  or  more  stiff 
hairs ;  the  claws  are  powerful  and  much  curved, 
e.g.,  Hippoboscidae  and  sheep-ticks. 

Suborder  IV.  Siphonaptera,  or  fleas,  are  by  some  considered 
to  be  wingless  diptera;  but,  if  so,  they  are  so  much 
modified  that  they  are  best  considered  separately, 
and  will  be  considered  in  Part  III.  in  connection 
with  plague. 


APPENDIX 


229 


Of  the  other  insects  that  are  blood-suckers  and  are  possibly 
carriers  of  disease  are  several  that  belong  to  tlie  Hemiptera, 
or  bugs.  The  Hemiptera  are  readily  distinguished  from  otlier 
insects  by  the  peculiar  moutli-parts. 

IV.— Ticks. 

Blood-suckling  Arthropods  are  found  also  amongst  the 
Arachnidse,  which  in  the  adult  stage  are  readily  distinguished 
from  the  insects,  even  from  the  wingless  insects,  by  the 
presence  of  four  pairs  of  legs  and  the  absence  of  antennse, 
whilst  the  orifice  of  the  mouth  is  a  small  slit. 

The  blood-sucking  groups  are  the  Ixodid^. 


Fig.  54. — Mouth-parts  of  Ixodes. 


IxoDiD^  have  either  a  hard  and  chitinous  or  thick,  leathery 
skin.  The  mouth-parts  consist  of  a  central  hypostome  armed 
with  teeth  projecting  backwards,  and  on  each  side  a  powerful 
chelicera,  also  armed  with  teeth  projecting  backwards,  clicliccrcB, 
enclosed  in  a  sheath.  There  are  a  pair  of  four- jointed  palps 
or  pedipalps. 

The  opening  of  the  genitalia  is  on  the  under  aspect  near  the 
head,  and  respiration  is  conducted  by  a  pair  of  sieve-like 
openings  in  the  respiratory  areas,  situated  close  to  the  bases 
of  the  fourth  pair  of  legs. 


230  TROPICAL   MEDICINE   AND    HYGIENE 

There  are  two  great  groups  of  the  IxodiD/E,  Ixodinm  and 
ArgasincB. 

IxoDiN/E. — The  rostrum  projects  from  the  anterior  extremity 
of  the  body.  The  palps  are  deeply  grooved  on  their  inner 
aspects  and  act  as  a  sheath  to  the  rostrum.  The  last  joint 
of  the  palps  is  a  small  projection  from  the  third.  The  second 
joint  is  long  in  one  division,  Ixodinae  (fig.  54),  and  shorter,  as 
broad  as  long,  in   another  :    Rhipicephalge  (fig.  55).     On  the 


Fig.  55.  — Mouth-parts  of  Rhipicephaliis. 

dorsal  aspect  is  a  hard  chitinous  plate,  dorsal  shield,  covering 
the  entire  dorsum  in  the  male  but  only  the  anterior  part  in  the 
female.  The  Ixodince  are  important  as  the  carriers  of  piro- 
plasma  in  the  lower  animals.  They  are  not  proved  to  carry 
any  disease  to  or  from  man. 

Argasin^  differ  from  Ixodinae  in  that  (i)  the  rostrum  is 
on  the  under  surface  of  the  body  ;  (2)  the  palps  do  not  form 
a  sheath  for  the  rostrum  ;  (3)  they  have  no  dorsal  shields,  but 
a  thick  leathery  covering  ornamented  with  knobs  or  bosses, 
making  a  regular  pattern. 

There  are  two  genera  : — 

A  rgas. — Body  with  sharp  edges.  The  pattern  of  the  marking 
close  to  the  edge  differs  from  that  on  the  rest  of  the  dorsum. 
Species  of  this  genus  carry  the  avian  spirochsetes. 

Omithodonis. — Body  with  rounded  edges.  No  difference  in 
the  pattern  of  the  marking  on  the  edge  from  that  of  the  rest 
of  the  dorsum. 


APPENIJIX 


231 


Oniithodorus  moiibaisa  carries  Spivochcvta  diUloni,  the  cause  of 
the  African  form  of  relapsing  fever. 

V. — Subdivision  of  the  more  Important  Groups 

OF    THE    DiPTERA. 

Of  the  groups  into  which  the  Diptera  are  divided  the 
Nematoceva  vera  and  the  Cyclovrhapha  schizophora  are  of  the  most 
importance  to  us,  as  some  of  them  are  proved  to  be  carriers 
of  important  diseases.  Many  of  the  others  are  blood-suckers, 
others  are  important  as  mechanical  carriers  of  baciliary 
diseases,  and  others,  both  of  the  dipterous  and  other  insects, 


Fig.  56.— Mouth-parts  of  Ornithodorus. 


are  important  as  destroyers  of  larvae  of  dangerous  species 
and  in  many  cases  do  much  injury  to  growing  crops,  to  fruit, 
grain,  &c. 

Nematocera  vera  are  subdivided  according  to  their  wing  vena- 
tion mainly.  This  venation  varies  greatly  in  the  members  of 
the  group,  and  the  family  known  as  the  CuHcidae  are  charac- 
terized by  having  scales  on  the  veins  of  the  wings  and  by 
the  forking  of  the  2nd,  4th  and  5th  longitudinal  veins.  These 
characters  of  the  wings  separate  the  Culicidae  from  all  other 
Nematocera  vera.  The  subdivision  of  the  Culicidas  is  made 
on  variations  of  the  mouth-parts  mainly  into  subfamilies,  and 
at  this  point  various  difficulties  arise  and  other  schemes  have 
been  proposed,  some  based  on  larval  characters  and  others  on 
those  of  the  eggs.     Each  of  these  methods  would  lead  in  somo 


■23- 


TROPICAL   MEDICINE   AND    HYGIENE 


cases  to  quite  a  different  grouping  and  in  others  would  make 
very  little  difference.  It  must  always  be  borne  in  mind  that 
any  grouping  founded  on  a  single  character  is  unsatisfactory, 
the  larger  the  number  of  the  characteristics  that  show  a 
marked  difference  the  sounder  is  that  classification. 
The  important  subdivisions  of  the  Culicidae  are  : — 
CoRETHRiN^. — Proboscis  adapted  for  suction  and  not  for 
penetration. 


Fig.  57. — Neuration  of  wing  characteristic  of  Culicidae  (Theobald). 


Megavhinina. — Proboscis  very  long  and  curved.  Palps  long, 
ist  fork  cells  in  wings  very  short.  Scales  on  veins  of  wings 
small.  Scutellum,  lateral  lobes  very  small.  Larvae  are  lar- 
viverous.  Very  short  respiratory  siphon.  Eggs  oval,  thick 
shelled. 

Anophelina. — Proboscis  straight.  Palps  same  length  as  the 
proboscis  in  both  sexes,  clubbed  in  male.  Scutellum  not 
lobed.  Scales  on  veins  of  wings  usually  lanceolate.  Scales 
on  thorax  and  abdomen  rarely  abundant.  Larvae  asiphonate. 
Eggs  with  lateral  air-floats. 

Culicina. — Proboscis  straight.  Palps  short  in  female,  in 
male  as  long  or  longer  than  the  proboscis.  Wing  scales 
variable.  Scales  on  thorax  and  abdomen  abundant.  Scutellum 
trilobed.  Larvae  always  siphonate  ;  the  siphon  may  be  long  or 
short.  Eggs  variable  ;  may  be  in  rafts  or  thick-shelled  eggs, 
deposited  singly. 

^Sdina. — Proboscis  straight.  Palps  short,  often  very  short 
in  both  sexes.      Scutellum  trilobed.      In  some  genera  hairs  on 


Al'lM';NiJlX 


233 


Probosc 


Basal         _ 

lobes  of  Q    ^^ 
V    Ma 


Basal 
lobes. 

Clasper.. 

n    u  ^Headof9 

Proboscis. 

Palpi 

Antennae -W(---¥///Clype 

Basallobesofanlennae    ^^^      P~VT^  yr 

Frons.... 

Vertex... 

Eyes 

Occiput. 
Nope  -- 

Fig.  5S. 
16 


--5^  tarsal 


'234  TROPICAL   MEDICINE    AND    HYGIENE 

metanotum.  Wing  scales  variable.  Scales  abundant  on 
thorax  and  abdomen  and  often  very  long  hairs  on  thorax. 
Larvae  always  siphonate,  in  some  the  siphon  is  very  short,  and 
these  lie  flat  on  the  surface  of  the  water  and  much  like 
Anopheline  larvae,  in  others  siphon  is  long.  Eggs  often  in 
loose  rafts,  but  may  be  laid  singly. 

There  are  two  other  subfamilies,  Heptaphlebomyina  and 
Joblotinci.  In  the  former  there  are  scales  on  the  7th  or 
accessory  veins,  and  in  the  latter  scales  and  hairs  on  the 
metanotum. 

Nothing  is  known  as  to  the  pathogenic  properties  of  the 
^dina ;  many  of  them  are  vicious  day  biters.  In  jungle, 
in  mangrove  swamps  and  elsewhere  they  are  common 
mosquitoes. 

Culicincs  are  subdivided  into  many  genera  by  the  character 
of  the  scales  on  the  head,  scutellum,  wings  and  elsewhere. 
Other  points,  such  as  the  character  of  the  palps,  of  the  male 
genitalia  and  antennae,  also  serve  for  the  purpose  of  sub- 
dividing a  group  that  is  too  large  to  be  convenient. 

In  some  genera  the  wing  scales  are  most  characteristic,  as 
in  Mansonia  and  Mucidiis  (fig.  24) ;  in  others,  the  scales  on  the 
head  and  scutellum  ;  and  it  is  the  characters  of  these  scales 
that  separate  the  Stegomyia,  as  there  are  only  square-ended 
scales  on  the  scutellum,  instead  of  narrow-curved  scales  as  in 
Culex,  and  square-ended  scales  with  a  few  upright  scales  on 
the  head,  instead  of  narrow-curved  scales,  upright  scales,  and 
at  the  sides  only  square-ended  scales  as  in  Culex. 

AnophelincB  are  subdivided  also  on  scale  characters  ;  but 
with  this  group  it  is  the  scales  on  the  thorax,  abdomen 
and  ventral  surface  of  the  abdomen  that  are  of  most 
importance,  though  variations  in  the  wing  scales  are 
a  subsidiary  aid. 
Anopheles  are  devoid  of  scales  on  thorax  and  abdomen, 

and  the  scales  on  the  wings  are  all  the  same  colour. 
Myzomyia. — No  scales  on  abdomen,  scale-like  hairs  on 
the  thorax— more  like  scales  on  the  anterior  margin 
of  the  thorax ;  but  the  scales  of  the  wings  are  of  two 
colours  and  smaller  and  narrower  than  in  Anopheles. 
Pyvetophonis. — Upright  fork  and  narrow-curved  scales  on 
head,  narrow-curved  scales  on  thorax,  hairs  only  on 
abdomen,  wings  scales  are  bluntly  lanceolate. 


AI'PENDIX 


235 


Fig.  59. — Types  of  scales,  a  to  k.  Head  and  scutellar  ornamentation,  i  to  5  : 
I,  Head  and  scutellum  of  Stegomyia,  &c. ;  2,  of  Culex  ;  3,  of  ^des,  &c.  ; 
4,  of  Megarhinus,  &c.  ;  5,  of  Cellia  and  some  other  Atiophelina  (Theobald). 


Cellia. — Numerous  scales  on  abdomen,  and  fusiform  scales 
on  thorax.  On  the  ventral  aspect  of  the  abdominal 
segments  are  tufts  of  long  dark  scales  which  project 
laterally  ;  these  may  arise  only  from  the  ventral  surface 
or  from  the  latere- ventral  aspect. 


236 


TROPICAL    MEDICINE   AND    HYGIENE 


Nyssovhynchiis. — Upright  fork  and  narrow-curved  scales 
on  head,  narrow-curved  and  spindle-shaped  scales  on 
thorax,  last  one  or  two  segments  of  abdomen  scaled 
dorsally,  latero-dorsal  patches  of  scales  over  rest  of 
abdomen  and  ventral  scales. 

Myzovhynchiis. — Numerous  upright  fork  scales  and  a  few 
narrow-curved  scales  on  head,  narrow-curved  scales 
on  thorax,  and  dense  tufts  of  upright  scales  on  pro- 
thoracic  lobes,  last  two  segments  of  abdomen  scaled, 
tuft  on  last  segment  ventrally,  densely  scaled  palps 
and  proboscis. 


Fig.  60. — Hamatopota  pluvialis. 


Nematocera  anomalainclvides  several  biting  flies,  such  as  sand- 
flies. Wing  venation  is  in  this  group  also  of  prime  importance 
in  dividing  them  into  families,  but  other  points  are  considered. 

Brachycera  anomala  also  includes  many  biting  flies,  as  the 
Tabanidae.  The  antennae,  and  particularly  the  relative  length 
of  the  2nd  joint  and  the  form  of  the  3rd  joint,  is  the  point 
of  importance ;  though  the  mouth -parts,  the  colouring  or 
mottling  of  the  wings  and  the  character  of  the  proboscis  are 
all  used  to  aid  the  division  into  genera.     The  wing  venation 


APPENDIX  237 

in   most  of  the  genera   Tahamis,   Ilcvmatopola,   &c.,  is  similar, 
and  in  these  there  is  a  central  closed  discal  cell  (fig.  61). 

The  Cyclorvhapha  schizopliora  include  many  important  genera. 
These  are  divided  into  those  in  which  the  halteres  are  covered 
viAith  a  semilucent  plate  or  scale — the  squama  ;  these  are  called 
calyptvata ;  when  there  are  no  such  covers  to  the  halteres  the 
insect  is  said  to  be  acalyptrate. 


Fig.  61. — Wing  of  a    Tabanus. 

The  important  division  of  the  calyptvate  schizophora  is  the 
MuscidiB.  In  these  the  antennae  are  dependent,  the  wing 
venation  is  simple,  there  is  no  closed  central  discal  cell  and  the 
marginal  cells  are  all  open  (fig.  62).  They  can  be  divided  into 
those  with  mouth-parts  formed  for  penetration  and  into  those 
only  capable  of  suction.  These  latter  include  the  common 
house-fly,  Miisca  domestica,  and  also  several  genera  which 
deposit  their  larvae  in  wounds  on  the  skin. 


Fig.  62. — Wing  of  Stonioxys  calcitrans. 

Those  with  mouth -parts  formed  for  penetration  are 
subdivided  by  the  character  of  the  penetrating  parts,  by  the 
palps  and  the  hairs  on  the  arista  of  the  antennas,  as  well  as  by 
minor  differences  in  the  wing  venation  and  particularly  in  the 
4th  longitudinal  vein. 


238  TROPICAL   MEDICINE   AND   HYGIENE 

Stomoxys. — The  proboscis  is  elbowed  at  the  base,  is  thick 
and  comparatively  short.  The  palps  are  short  and  thin  and 
do  not  form  a  sheath  to  the  proboscis.  The  hairs  on  the  arista 
are  on  the  upper  side  of  the  arista  only,  whilst  the  4th 
longitudinal  vein  is  not  abruptly  bent,  but  slightly  curved. 

Glossina. — The  proboscis  is  long  and  projects  straight  out 
from  the  head.  The  palps  are  thick,  the  same  length  as  the 
proboscis  and  grooved  on  their  inner  aspects.  Together  they 
form  a  sheath  for  the  proboscis.  The  hairs  on  the  arista  are 
compound  and  are  on  the  upper  surface  only.  The  4th  longi- 
tudinal vein  is  angled  twice. 


INDEX. 


PAGE 

Abdomen,  distension  of,  in  kala-azar          ...         ...         ••.         ...  •■•     I45 

Abortion : — 

Spontaneous,  in  malarial  fever,  prevention 43'  44 

Subtertian     29 

In  relapsing  fever            ...         ...         ...         ...         ••■         •••  •■      178 

Abscess  of  liver  associated  with  amoebic  dysentery            223,224 

Abscesses,  'mtei-na.],  due  to  Eu^amaia  kzsto/yiica  ...         ...         ...  ...     222 

Africa  : — 

Blackwater  fever,  prevalence  in  malarious  districts  ...  ...  ...  102 

South,  trypanosomes  found  in  ...         ...  ...  •.  ••.  -.-  13° 

Tropical,  blackwater  fever  prevalent  in  ...  ...  ...  ...  87 

Human  trypanosomiasis             ...         ...  ...  .••  ••■  •■•  131 

Agnottidce :  see  Dragon-flies. 
Albuminuria  : — 

In  subtertian  malaria      ...         ...         ...  ...  •••  •••  28,  30 

Toxic  effect  of  malarial  parasite            ...  ...  ...  ...  ...  64 

In  yellow  fever 109,110,111 

Alimentary  canal,  invasion  by  coccidia        ...  ...  ...  ...  •.■  4 

Alkaloid,  percentages  of,  in  salts  of  quinine  34 

Amblyopia  in  malarial  cachexia        ...         ...  ...  •■•  ••■  ••■  46 

Amaindcc          ...         ...         ...         ...         ...  •••  •■■  •••  •••  5^ 

Amceba ...         ...         ...         ...         ...         ...  •■•  •••  ■••  •••  218 

Scheme  of  development 219 

Autogamy  in        ...         ...         ...         ..           ...  ••■  •••  ■••  220 

Date  of  discovery            ...         ...         ...         ...  ••■  •••          •••  225 

Encysted  forms    ...         ...         ...         ...         ■■•  •••  ■-          ••■  220 

Infective  agents        ...         ...         ...         .••  ...  ■••         •••  220 

Amcebina          ...         ...         .-         ...         ...         •••  •••  •••         •••  218 


240 


INDEX 


Ansemia :  — 

In  blackwater  fever 

In  kala-azar 

In  malarial  cachexia        ... 

Masked  by  bronzing  of  skin 
Anasarca  in  kala-azar  .. . 
Anopheles 
Anophelina 
Anophelines :  — 

Breeding  places  of,  important    ... 

Conveyance  of  malaria  parasites  from  man  to  man  by 

Determination  in  given  localities  of  malaria-carrying  species 

Species  of,  carriers  of  malaria    ... 

Points  of  distinction  from  other  mosquitoes 
Antimony  injections : — 

In  human  trypanosomiasis 
Appetite  in  kala-azar  ... 
Argas     ... 

persicus.  Spirillum  gallinarum  transmitted  by 
Argasina 
Arsenic,  effect  of,  in  human  trypanosomiasis 

See  also  Atoxyl. 
Arthropods 
Aschiza... 
Assam  : — 

Kala-azar  in 

Mortality  from  excessive    . . . 
Athene  nodiice,  see  Oivl  {^Little). 
Atoxyl,  injections  of,  in  human  trypanosomiasis    ... 
Atrophy,  acute  yellow,  of  liver  simulating  yellow  fever 

Bacillus  typhosus,  conveyance  by  flies 
Bacteria,  conveyance  by  insects 
Balantidium  coli 

Date  of  discovery 
Barbados,  freedom  from  malaria 

Bath-tubs,  hatching  place  for  eggs  of  Stegoniyia  fasciata 
Baths,  cold,  in  reduction  of  high  temperature  in  malaria 
Bed-bug,  Indian,  probable  carrier  of  kala-azar  parasite 
Bentley,  etiology  of  kala-azar 
Birds,  halteridium  in  ... 
Black  vomit : — 

In  relapsing  fever 

In  yellow  fever     ... 
Blackwater  fever  

In  Africa,  in  areas  of  greatest  malarial  prevalence 

Ansemia  in 

Causal  organism  undiscovered  ... 


01 

150 

44 

45 

151 

234 

232 

80 

15 

"84 

,85 

67 

68 

137 

145. 

165 

230 

185 

194. 

230 

135 

229 

228 

144, 

152 

159 

136 

III 

10 

10 

217 

225 

66 

119 

41 

•63, 

165 

i6i 

124 

177 

no 

87 

102 

89,95 

9i 

INDEX  241 

Black  water  fever : —  I'AfiR 

Caution    in    giving    quinine    to   malarial    patients    previously    the 

subjects  of         ...         ...         ...         ...         ...         ...         ...       44 

Clinical  course      ...         ...         ...         ...         ...         ...         •••         ■•■       87 

Close  connection  with  malaria  ...         ...         ...         ...         ...  95>  '°3 

Danger  from  suppression  of  urine         ...         ...         ...         ...    93>  95»  ''^ 

Deposits  of  hcxmosiderin  in  kidney,  liver,  and  spleen  96 

Diagnosis  ...  ...  ...  ...  ...  •■•  ■••  •••  ••■        93 

Differential,  from  yellow  fever       111,112 

Made  from  state  of  urine    ...         ...  ...  ...  ••         ••.       93 

By  spectroscopic  test  ...         ...         ...  ..  ■•.  94)95 

Discharge  of  hemoglobin  in  urine  should  be  aided,  not  checked     ...       97 

Etiology "32 

Quinine  poisoning,  hypothesis  discussed 102,103 

Examination  of  urine  in 88,91 

Geographical  distribution  87 

Hemolysis  in        91,92-96,97 

Hiccough  in  89,95 

Jaundice  in  89,90 

Liability  to  subsequent  attacks  ...  ...         ...         ...         ...         ■••       95 

Afyzomyia  funesta  in  vfoxst  districts     ...         ...         ...         ...         ...     I02 

Nursing 99 

Pathological  anatomy      ...         ...         ...         ...         ...         ••■         •••       95 

Pigment  present  in  liver  and  spleen      9^ 

Piroplasma  not  associated  with  ...         ...         ...         ...  •■•  87,104 

Prevention  of  relapse      ...         ...         ...  ...         ■••  •••         •••     1°^ 

Prognosis...  ...  ...  ...  •••  •••  ■••  ■••  •■•       95 

Prolonged  immunity  to  malaria  conferred  by  attack  of         92 

Prophylaxis  I04 

Recurrent  attacks  ...  ...  ...  ■••         •••         •••         ••■       95 

Risks  of  travelling  during  attack  loi 

Secondary  fever  in  ...         ...         ...  •••  •••  ■••         •••       92 

Sequelae '°3 

Treatment  9^ 

Diuretic         98 

By  drugs,  without  specific  action 96.97 

By  rectal  enemata  of  saline  solution         ..  98,100 

Urine  in,  colour  similar  to  that  of  urine  in  paroxysmal  ha;moglobinuria       93 

Vomiting  in  89,93,100 

Blair,  on  stages  of  yellow  fever         no 

Blood,  examination  of,  in  diagnosis  of  kala-azar 150,153,154 

of  malaria      ...         ...  ■•.         ...30,31 

In  relapsing  fever  ...         ...         ...         ••.         .••     180 

Diminution  in  kala-azar 15° 

Blood-films,  in  examination  of  malarial  parasites 49 

Appearances  seen    ...         ...         ...  ...         •■•  •■•  ^2,  03 

Schiltiner's  dots        61 

Stained  ...  ...  ..•  •••  •••  ■••  ■••  ■  •        ^^ 

Blood-serum  from  yellow-fever  patient,  infectivity 113,114 

17 


•  242  INDEX 

PAGE 

Blood-stasis  in  subtertian  malaria,  abdominal         ...  ...  ...  26,27 

Cardiac...          ...  ...  ...  ...       28 

Convulsions  in ...  ...       26 

Cerebral            ...  ...  ...  24,  26 

Pulmonary        ...  ...  ...  ...       26 

Rarity  in  Benign  fevers  ...  ...       24 

Bombay,  mortality  from  relapsing  fever  at ...         ...  ...  ...  ...     179 

Bone-marrow,  a  seat  of  parasite  in  kala-azar           ...  ...  ...  ...      1 56 

Boophilus  decoloraius,  Spirilliiai  theile?-i  ix^nsmitttAhy  ...  ...  ...     185 

Boracic  acid,  in  treatment  of  black  water  fever        ...  ...  ...  ...       98 

Brackycera        ...          ...          ...          ...          ...          ...  ...  ...  ...227-8 

anomala     ...          ...          ...          .......          ...  ...  ...  228,  236 

vera            ...          ...          ...          ...          ...          ...  ...  ...  ...     228 

Brain,  histological  changes  in  sleeping-sickness      ...  ...  ...  ...     135 

Breinl,  on  tick  fever    ...         ...         ...         ...         ...  ...  ...  ...     191 

British  troops  in  India,  severity  of  syphilis  greater  than  among  native  ...     200 
Bronchitis : — 

In  kala-azar          ...         ...         ...         ...         ...  ...  ...  145,  152 

In  tick  fever         ...         ...         ...         ...         ...  ...  ...  ...     192 

Cachexia  : — 

Of  kala-azar         ...          ...          ...          ...          ...  ...  ...  146,  149 

Malarial     ...          ...          ...          ...          ...          ...  ...  ...  ...       44 

Diagnosis  of  kala-azar  from            ...          ...  ...  ...  ...      153 

Enlargement  of  liver  and  spleen  in          ...  ...  ...  ...       45 

Ocular  disturbances  in        ...          ...          ...  ...  ...  ...       45 

Symptoms  associated  with..           ...          ...  ...  ...  ...       45 

Treatment  of            ...         ...         ...         ...  ...  ...  45>  4^ 

Climatic            ...         ...         ...         ...  ...  ...  ...       46 

Dietetic...         ...         ...         ...         ...  ...  ...  ...       45 

"  Caledonia"  S.S.,  relapsing  fever  on  board          ...  ...  ...  ...     187 

Cancrum  oris  in  kala-azar       ...          ...          ...          ...  ...  ...  ...     152 

Carroll  and  Reed,  infective  agent  in  yellow  fever...  ...  ...  ...     114 

Cattle  :— 

Piroplasmosis  in   ...         ...         ...         ...         ...  ...  ...  105,  106 

Inoculation  against  rinderpest  leading  to  infection  ...  ...     107 

Universal  infection  ...          ...          ...          ...  ...  ...  ...      107 

See  also  Red-water  fever. 

Trypanosoma  diniorphon...          ...          ...          ...  ...  ...  ...     130 

Trypanosoma  theileri      ...          ...          ...          ...  ...  ...  ...     130 

Cellia     ...          ...          ...          ...          ...          ...          ...  ...  ...  ...     235 

Cerebro-spinal  fluid,  trypanosomes  in  sleeping  sickness  ...  ...  ...     134 

Cess-pits,  hatching  place  for  eggs  of  6". ya.ff /a/a      ...  ...  ...  ...      119 

Chamberlain,  Right  Hon.  J.,  one  of  the  Founders  of  English  Tropical 

Schools          ...         ...         ...         ...         ...  ...  ...  ...     226 

Chigoe  {SarcopsyUa penetrans),  csmitr  of  yzws      ...  •  ...  ...  ...     211 

Children  :— 

Convulsions        during  attacks  of  subtertian  malaria ...  ...  ...       26 


INDEX  243 

Children  :  I'AGK 

Determination  of  n^c  at  which  larfje.st  proportion  of,  arc  infected 

by  malaria          ...          ...          ...          ...  ...  ...  ...       82 

Oriental  sore  affeclinj^     ...          ...          ...          ...  ...  ...  ...      170 

Subtertian  malaria  in       ...          ...         ...         ...  ...  ...  ...       24 

(Jiliata  ...          ...         ...         ...         ...          ...         ...  ...  ...  ...         3 

Ciniex  rotundaius  (Indian  bed-bug),  as  carrier  of  kala-azar  ...  163,  165 
Cisterns  : — 

Cleansing  of  in  prophylaxis  of  yellow  fever      ...  ...  ...  ...     120 

Hatching  place  of  eggs  of  .S'/^^iJwj/m/aj-r^a/a...  ...  117,  118,  119 

Climate  in  malarial  cachexia              ...         ...          ...  ...  ...  ...       46 

Coccidia  : — 

Development  and  life  history     ...         ...         ...  ...  ...  ...         4 

Reproduction  and  hosts  ...          ...         ...         ...  ...  ...  ...       12 

Coko :    see  Yaws. 

Cold  compresses,  application  in  yellow  fever          ...  ...  ...  ...     113 

Coma,  malarial,  treatment  by  hot  packs      ...          ...  ...  ...  40,  41 

Congo  district,  human  trypanosomiasis        ...          ...  ...  ...  ...      131 

Convulsions  in  subtertian  malaria  in  children          ...  ...  ...  ...       26 

Coolie  lines,  separation  from  European  quarters  in  prevention  of  malaria       80 

Copper  sulphate  solution  in  treatment  of  Oriental  sores    ...  ...  ...     171 

Corethrincc        ...          ...          ...          ...          ...          ...  ...  ...  ...     232 

Corpuscles,  "  brassy "...         ...         ...         ...         ...  ...  ...  ...       51 

"  Crescents"  of  subtertian  malarial  fever  ...         ...  ...  22,  30,  57,  62,  63 

Cropper,  bodies  in  severe  forms  of  malaria...         ...  ...  ...  ...     108 

Cw/zV/afe,  neuration  of  wing  characteristic  of         ...  ...  ...  ...     232 

Cidicina           232,  234 

Characteristics      ...         ...         ...         ...          ...  ...  ...  ...     115 

Cunningham,  parasite  of  Oriental  sore        ...         ...  ...  ..  ...     169 

Cyclorrhapha    ...         ...         ...         ...         ..           ...  ...  ...  ...     228 

schizophora            ...          ...          ...          ...          ...  ...  ...  231,  237 

Cj//;7«ort(7«//^fr,  destruction  of  mosquito  larvK  by  ...  ...  ...       78 

Deafness  caused  by  quinine  in  malaria      ...         ...  ...  ...  ...       46 

Delhi  boil  :  see  Oriental  sore. 

Diarrhoea  associated  with  Ztzwi^/zfl!  ?'«/'£5'/?Via/?i'      ...  ..  ...  ...     217 

In  kala-azar          ...          ...          ...          ...          ...  ...  ...  I46,  151 

Diet  :— 

In  kala-azar          ...         ...         ...         ...         ...  ...  ...  ...     165 

In  malaria            ...         ...         ...         ...         ...  ..  ...  ...       43 

During  convalescence         ...         ..           ...  .-.  ...  ...       43 

In  malarial  cachexia        ...          ...          ...          ...  ...  ...  45j  4^ 

In  relapsing  fever            ...         ...         ...         ...  .-■  ...  •■■     18S 

Diptera  : — 

Classification  of  ...          ...          ...          ...          ..  ...  ...  ...     227 

Subdivision  of  more  important  groups  of        ...  ...  ...  -.     231 

Dirt  and  overcrowding  favourable  to  spread  of  relapsing  fever   ...  ...      187 

Diuretic  treatment  of  blackwater  fever        ...         ...  ...  ...  ■-.       98 


244  INDEX 

PAGE 

Dogs  : — 

Piroplasmosis  in  ...          ...          ...          ...          ...          ...  ...  105,      106 

See  also  Jaundice  epidemic. 
Donovan  :  see  Leishman- Donovan  bodies. 

Dourine...  ...         ..  ...         ...         ,..         ...         ...  .....       130 

Dragon -flies,  larvae  of,  destruction  of  larvae  of  mosquito  by  ...  ...       78 

Drainage,  extermination  of  malaria-carrying  mosquitoes  by  ...  ...  75"77 

Of  settlements  and  plantations  in  extirpation  of  mosquitoes  ...  78-80 

Drinks  in  malaria         ...          ...          ...          ...          ...          ...  ...  ■         43 

Dum-dum  fever  :  see  Kala-azar, 

Dutton,  on  cause  of  tick  fever           ...         ...         ...         ...  ...  190,191 

Dysentery,  abscess  of  liver  associated  with...         ...         ...  ...  223,224 

Amoebic 223 

In  kala-azar           ...          ...          ...          ...          ...          ...  ...  146,  151 

Frequent  cause  of  death     ...         ...         ...         ...  ...  146,  149 

Malarial  patients  prone  to         ...         ...         ...         ...  ...  ...       47 

Dyspepsia,  atonic,  chronic,  caused  by  quinine        ...         ...  ...  46 

Chronic,  mistaken  for  malarial  cachexia         ...         ...  ...  ...       44 


Endemic  Index  in  Malaria,  determination  of 81 

Methods        81-86 

Enemata  of  saline  solution  in  treatment  of  blackwater  fever        ...  98,  100 

English  tropical  schools,  influence  of  ...         ...         ...         ...         ...     226 

Entamceha  buccalis      ...  ...  ...  ...  ...  ...  ...         ...     221 

hystolitica  ...  ...  ...  ...         ...  ...  ...  ...     221 

Internal  abscesses  due  to    ...         ...         ...         ...         ...         ...     222 

EntamabcB        ...         ...         ...         ...         ...         ...         ...         ...         ...     221 

Epistaxis  : — 

In  kala-azar  ...  ...  ...  ...  ...  ...  ...         145,  15 1 

In  relapsing  fever  ...         ...         ...         ...         ...         ...         ...     178 

In  subtertian  malaria       ...  ...  ...  ...  ...  ...  ...       26 

Epithelioma  of  penis,  diagnosis  of  pudendal  granuloma  from     ...  ...     215 

European  quarters,  separation  from  coolie  lines  in  prevention  of  malaria       80 

Europeans : — 

Incidence  of  tick  fever    ...  ...  ...  ...  ...  ...  ...      192 

Ftotecl'ion  horn  OmiiAodorus  mozibaia  ...         ...         ...         196,197 

Eye,  diseases  of,  complicating  malarial  cachexia    ...         ...         ...  45)46 


Famine  fever,  relapsing  fever  described  as            ...  ...  ...  ...  187 

Fever,  initial,  in  kala-azar     ...         ...         ...         ...  ...  ...  ...  146 

Fiji,  reason  for  absence  of  malaria  in          ...         ...  ...  ...  ...  66 

Fish,  species  of,  destruction  of  mosquito-larvae  by...  ...  ...  ...  78 

Fish-poison,  destruction  of  mosquito-larvse  by       ...  ...  ...  .-77-78 

Trypanoplasma  of            ...          ...          ...          ...  ...  ...  ...  128 

Fistula,  recto-vaginal,  accompanying  granuloma  of  pudenda  214 

Flagellata          ...         ...         ...         ...         ...         ...  ...  ...  ...  123 

Flagellum  of        ...         ...         ...         ...         ...  ...  ...  ...  123 


lO 


INDKX  245 

Flagellata  :—  ^'^^^ 

(Jroiip  of  protozoa           ...         ..•          ■.•          •••          •••         •••  ••         -^ 

Inclusion  of  parasite  of  kala-azar  in       161,162 

Flagellate,  resting-stage  of 106,128 

Flagellum          ...         ...           .•         •••         •••         •••         ■•         •■■  ■"         ^ 

Flies,  conveyance  of  typhoid  bacillus  by      

Food  :  see  Diet. 
Frambcssia  :  see  Yaws, 


Gametocytes  of  subtertian  malaria  

Sausage-shaped  bodies  (crescents)         

Geese,  septicoemia  in,  produced  by  Spirillum  anseniu     

Geographical  distribution  :  — 
Of  blackwater  fever 

Of  granuloma  of  pudenda  

Of  relapsing  fever 

Of  tropical  diseases,  dependence  on  parasites  producing  them 
Of  yaws     ... 
Of  yellow  fever     ... 
Glossina... 

Bites  

Carrier  of  human  trypanosomiasis         131 

Description  and  varieties 

Destruction  in  prophylaxis  against  human  trypanosomiasis 

Habitat  of... 

fiista  ^31 

maciilata    ... 
vioi'sitans  ... 
palpalis 
tachinoides 

Glycosuria  in  subtertian  malaria       

Gonorrhoea,  chronic,  diagnosis  of  granuloma  of  pudenda  from 
Granuloma  gangrenosa 

Granuloma  of  pudenda  

Clinical  course 
Diagnosis... 

from  epithelioma 
from  gonorrhoea 

Geographical  distribution  

Pathological  anatomy 
Prognosis  ... 

Recto-vaginal  fistulre  accompanying 

Treatment 
Granuloma  of  yaws 
Gregarinida 

Origin  of  ... 
Reproduction 

Grissoli's  symptom  in  human  trypanosomiasis         

"  Guam "  disease         


57 

57,  62, 

,63 

185 

87 

212 

172 

I 

203, 

204 

109 

131, 

238 

139 

I,  138, 

140 

138 

-142 

143 

139 

I,  13S, 

139 

138 

138, 

139 

131, 

138 

138 

28 

215, 

212; 

212 

213 

215 

215 

215 

212 

215 

215 

214 

215 

207 

12 

II 

12 

132 

211,213 

246  INDEX 

PAGE 

H/EMAMCEBA,  origin  of            II 

Points  of  difference  of  piroplasma  from  ...  ...  ...  ...  105 

Reproduction  and  hosts  ...         ...         ...  ...         ...  ...  ...  13 

Hismatobia  pluvialis  ...          ...          ...          ...  ...          ...          ...  ...  236 

Hcematopota      ...         ...          ...          ...          ...  ...          ...  ...  ...  237 

Heematuria  in  kala-azar           ...          ...          ...  ...          ...  ...  ...  151 

IlEcmocytozoa  :  see  Hcemosporidia. 

Haemoglobin,  discharge  in  urine  in  blackwater  fever         ...         ...  ...  97 

Hsemoglobinuria : — 

Mortality,  principal  cause          ...         ...  ...  ...  ...  ...  93 

(Paroxysmal),  similarity  of  urine  to  that  in  black  water  fever  ...  93 

In  piroplasmosis  ...         ...         ...         ...  ...  ...  ...  ...  106 

Endemic  :  see  Blackwater  fever . 

Hsemogregarinida,  origin  of  ...         ...         ...  ...  ...  ...  ...  11 

Reproduction  of  ...         ...         ...         ...  ...  ...  ...  I3)   14 

Hsemolysis : — 

In  blackwater  fever         ...         ...         ...  ...  ...  91,  92,  96,  97 

In  piroplasmosis  ...         ...         ...         ...  ...  ...  ...  ...  106 

Toxic  effect  of  malarial  parasite            ...  ...           ..  ...  ,..  63 

Haemorrhage : — 

From  mucous  surfaces  in  kala-azar       ...  ...  ...  ...  145,  151 

In  subtertian  malaria       ...         ...         ...  ...  ...  ...  ...  28 

(Cerebral),  fatal  in  relapsing  fever        ...  ...  ...  ...  ...  178 

Haemosiderin,  deposits  of,  in  kidney,  liver,  and  spleen  in  blackwater  fever  96 

Haemosporidia  : — 

Diseases  caused  by,  in  man        ...         ...  ...  , . .  ...  ...  15 

Origin  of  . . .         ...         ...         ...         ...  ...  ...  ...  ...  11 

Reproduction  and  hosts ...         ...         ...  ...  ...  ...  ...  13 

Halteridium      ...         ...         ...         ...         ...  ...  ...  ...  123,  124 

Fertilization  of     ...         ...         ...         ...  ...  ...  ...  ...  124 

Life-history  of      ...         ...         ...         ...  ...  ...  ...  124,  125 

Ookinet  of            ...         ...         ...         ..  ...  ...  ...  ...  124 

Havana,  prophylactic  measures  against  yellow  fever  at    ...  ...  ...  121 

Headache  in  yellow  fever      ...         ...         ...  ...  ...  ...  no,  112 

Hearsey,  treatment  of  blackwater  fever      ...  ...  ...  ...  ...  98 

Heart  :  see  Blood-stasis,  cardiac. 

Heart  failure  in  relapsing  fever         ...         ...  ...  ...  ...  ...  175 

Treatment    ...          ...         ...         ...  ...  ...  ...  ...  188 

In  subtertian  malaria       ...          ...          ...  ...  ...  ...  ...  29 

Heart  fever  (piroplasmosis  with  haemoglobinuria),  in  sheep  ...  ...  106 

Hepatitis,  amoebic       ...         ...         ...         ...  ...  ...  ...  ...  222 

Treatment  by  ipecacuanha        ...         ...  ...  ...  ...  ...  222 

Heptaphlebotiiyiiia       ...          ...          ...          ...  ...  ...  ...  ...  234 

Herpes,  labial,  in  subtertian  malaria            ...  ...  .,,  ...  ...  24 

Zfer/e/^;;/^«aj-,  difference  from  trypanosomes  ...  ...  ...  ...  128 

Hiccough  in  blackwater  fever           ...         ...  ...  ...  ...  •••89,95 

Horses  :  — 

Piroplasmosis  in  ...          ...          ...          ...  ...  ...  ...  105,  106 

Trypanosojua  di77iorphon  \.x\       ...         ...  ...  ...  ...  ...  130 


INDEX  247 

I'AGR 

Hosts,  intermediate,  of  parasites      1,8 

Hot  packs  in  treatment  of  malarial  coma 40i4i 

Ice-bags,  application  to  abdomen  in  yellow  fever            H3 

Immunity  to  malaria  after  blackwater  fever           92 

Slowly  acquired  by  repeated  attacks 81 

To  relapsing  fever,  acquirement  of       '85 

India : — 

Distribution  of  kalaazar  in        '45 

Epidemic  pmha.h\y  due  to  Feduulus  vesitmeniorum             185 

Possibility  of  human  trypanosomiasis  in          160 

Infusoria,  origin  of      ...          ...          .■•          ■•■          •••          •••          •••          •••  '^ 

See  also  Ciliala. 
Insects  :  — 

Conveyance  of  bacteria  by         ...         ...         ...         •••         ■•■          •••  1° 

Development  of  metazoa  in        ...          ...         ...         .••         ...          .••  10 

Of  protozoa  in          ...          ...          .■■          •■■          •••          ■■•          •■•  ^^ 

Infection  with  animal  parasites 9 

Methods        9.  1° 

Insomnia  in  malarial  cachexia           ...         ...         ...         •••         •■•         ••■  45 

Intestine,  inflammation  of,  in  kala-azar       156,157 

Intestines,  protozoa  found  in...         ...           .•         •••          •••         •••         ••■  217 

Intramuscular  injections  of  metallic  mercury  in  treatment  of  syphilis     ...  201 
Of  quinine  in  malaria          ...         •■•         •••         ■■•         •••             3"'  37 

Intravenous  injections  of  quinine  in  malaria            ...          ...          ...           ..  37 

Ipecacuanha  in  treatment  of  amoebic  hepatitis        ..           ..           ..            •■  222 

Irrigation  systems,  avoidance  of  harbourage  of  mosquitoes  in     80 

/xijfl^ifj,  mouth-parts  of            ...         ...         •••         •••         ■•■         •■■         ••■  229 

Ixodida 229 

Ixodina  194,230 

Jaundice  in  blackwater  fever  89,90 

epidemic  (piroplasmosis  with  hcemoglobinuria),  in  dogs       ...         105,  106 

Malaria  with,  simulating  yellow  fever iil 

In  relapsing  fever  ...         ...         ...         •■•         •••  •••         ■••     ^77 

In  yellow  fever 109,110 

Joblotina  234 

Jones,  Sir  A.,  one  of  the  founders  of  English  tropical  schools     226 

Kala-azar      144-167 

Abdominal  distension  in...         ...         ...         ■••           •■           ••  ■■•     I4S 

Age  incidence       ...         ...           ■•         ■■•         ••■           •■          •••  •••     '64 

Anaemia  in            ...         ...         ...         ■••         ■■•         ■••           •■  •■•     '5° 

Anasarca  in           ...          ...          ...          ■•.          ••■          ■••          ■■•  ■••      15^ 

Appetite  good  or  voracious  in    ...                     ...         ■••           ••  145,165 

Bronchitis  in         I45,  ^52 

Cachexia  of           146,149 

Cancrum  oris  in   ...         ...         ...         •••         •■•         .••         •■■  ••     152 

Clinical  course      ...         ...         ...         ...         ■■•  •••      '45 

stages  of        ...         ...         ...         ...         ...         •••         •••  •••      ^46 


248  INDEX 

Kala-azar  :  — 

Cutaneous  pigmentation  in 
Definition  ... 
Diagnosis  ... 

By  blood-examination 

By  demonstration  of  parasite 

By  diminished  number  of  leucocytes 

From  malaria,  by  quinine  test 

From  malarial  cachexia 
Diarrhoea  or  dysentery  in 
Duration    ... 

Dysentery,  frequent  cause  of  death 
Enlargement  of  liver  and  spleen  in       ...         ...      147 

Epistaxis  in 
Etiology    ... 

Mistakes  in  ...         ... 

Geographical  distribution 

Hsematuria  in 

Hemorrhage  from  mucous  surfaces  in  ... 

Incubation  period 

Intestinal  inflammation  in 

Mortality  excessive 

Parasites  of  ...  ...  ...  ..: 

History  of  discoveries  relating  to  ... 

Probable  carrier 

Similarity  of  parasite  of  oriental  sore  to 

Staining  for  ... 

Pathological  anatomy 
Pneumonia  in 
Prognosis  ... 
Prophylaxis 
Race  incidence     ... 
Relation  to  trypanosomiasis 
Seasonal  prevalence 
Spread  by  house  infection 
Treatment.., 

Dietetic 

Induction  of  leucocyto.sis    ... 
Tubercular  phthisis  in 
Kala-duakh :  see  Kala-azar. 
Kanailoma 

Karlinsky,  experiments  with  spirillum 
Kidney,  fatty  degeneration  in  yellow  fever  ... 

Hsemosiderin  deposited  in  tubules  of,  in  blackwater  fever 
Kinghorn  on  tick  fever 

Koch,  atosyl  injection  in  human  trypanosomiasis 
Experiments  as  to  cause  of  tick  fever    . . . 

Labour  gangs,  working  strength  badly  affected  by  malaria 
Lambkin,  Colonel,  treatment  of  syphilis  in  Army... 


150.  153. 

150. 

44,  152, 
146, 

146, 

151.  155. 
145. 


145. 


PAGE 
•52 


156, 

156, 
160, 


57, 


60, 


INDEX  '•^49 

I'AOR 

Laniblia  iiileslinalis    ... 

Date  of  discovery  -" 

Diarrhrt-a  associated  with  ...  ...  ■•  •  ■•  •■■  ' 

Lanolin,  metallic  mercury  in,  intra-muscular  injections 201 

Larvre:  see  DI^gon■mes,  Mosqukoes,  .S/e.s^omyia /ascia/a. 

Leishman,  W.  B.,  possible  occurrence  of  trypanosomiasis  in  India        ...     160 

Leishman's  method  of  staining  for  malarial  parasites        3° 

Modification  of  Romanowsky's  stain 49.  59.  '02 

Description  of  59. 

Leislimania  donovani 

Leishman-Donovan  bodies     ... 

TA-  f  ...      160,     161 

Discovery  ot 

T-.  ^  ...      225,     226 

Date  ...  ...  ■■•  ■■•         •••         •••         ■■■  -" 

Resemblance  to  trypanosomes •  '^ 

Resting-stage  of  flagellate  '°^'  '^^ 

Lemon  grass  tea  as  drink  in  malaria  "^3 

Leucocytes,  mononuclear,  large,  in  diagnosis  of  malaria  ...         ...         •■■  3' 

Pigmented,   discovery  by  blood    examination,  aid  to  diagnosis  of 

malaria           ...          .•■           ■•          ••■          •••          •■•          ■■'          ■'        -^ 
Leucocytosis,  induction  of,  in  treatment  of  kala-azar        io5 

Leucopenia  in  kala-azar         ...         ...         ■■•         ••■  •••         ••  5  >    54 

Lips  :    see  Hei-pes,  labial. 

Liver,  abscess  of,  associated  with  amcebic  dysentery         223,224 

Acute  yellow  atrophy  of,  simulating  yellow  fever      "i 

Enlargement  in  kala-azar  147,148.151.156 

In  malarial  cachexia  ...  ...  •.•         •••         •■■         •■       45 

In  relapsing  fever 177.  i'52 

In  tick  fever '9^ 

Fatty  degeneration  in  yellow  fever       ^'3 

Hemosiderin  deposited  in  cells  of,  in  blackwater  fever        96 

Pigment  present  in,  in  blackwater  fever  ■•■      32.  33.  9^ 

Puncture  of,  to  obtain  parasite  of  kala-azar '55 

Seat  of  parasite  in  kala-azar      '5" 

London,  Port  of,  relapsing  fever  in ••■         •■•     ^°7 

Lumbar    puncture,   discovery    of    trypanosomes    in    cerebrospinal    fluid 

during  sleeping  sickness  by        ...         ...         ■••         •■•         ■••         ••     'j4 

Lungs,  pneumonic  consolidation  of,  in  relapsing  fever      182 

See  also  Blood-stasis,  pulmonary  ;  Pneumonia. 

Lymphatic  glands,  enlargement  in  trypanosomiasis  132 

Swelling  and  inflammation  in  relapsing  fever 178 

Important  in  diagnosis  from  plague  178 

McCallum,  on  fertilization  in  halteridium  124 

Mackie  :  — 

Difterences  in  parasites  of  varieties  of  relapsing  fever            198 

School  epidemic  probably  due  to  Pedicultis  vcstiinento)  itvt 185 

Macrogametes  : — 

Of  coccidia           ...          ...         •••         •••       ,  •••         ••■          •••         ••■  4 

Of  malarial  parasites       ...         ...         ...         •••         •••         •■■         ••■  55 


250 


INDEX 


153 


PAGE 


77 

102 

44 

74.  75 


Macrogametes  :  Micropyle  of 
Madras,  kala-azar  in    ... 
Malaria : — 

Absence  of,  on  plantations  well  managed  and  well  drained., 
Blackwater  fever  in  Africa  in  areas  of  greatest  prevalence  of 
Cachexia  following 
Carriers  of,  species  of  Myzomyia 

See  also  Anophelines,  Mosquitoes,  malaria-carrying,  Myzomyia 
funesta. 
Classes  liable  to  attack  in  regions  of  prevalence         ...         ...  72,73 

Clinical  varieties  of         ...         ...         ...         ...         ...         ...         ...       16 

Close  connection  with  blackwater  fever  ...         ...         ...  95,  103 

Co-existence  with  kala-azar        ...         ...         ...         ...         ...         ...     153 

Coma  in,  treatment         ...         ...         ...         ...         ...         ...  40,41 

Complicated  by  pregnancy         ...         ...         ...         ...  ..         ...       43 

Determination  of  age  at  which  largest  proportion  of  children  are 

infected  by 
Diagnosis  of  relapsing  fever  from  ..,         ...         ...         ...         179, 

Diminution  by  reduction  of  mosquitoes 

Enlargement    of  spleen   in  ;    examination   for,    method  of  testing 

endemic  index  ... 
Etiology     ... 

Transmission  of  parasite  by  mosquito 
Freedom  from,  ensured  by  protection  from  bite  of  mosquitoes 
Geographical  distribution  ...         ...         ... 

Immunity  to 

Prolonged,  conferred  by  attack  of  blackwater  fever 
Slowly  acquired  by  repeated  attacks 
Incubation  period 

With  jaundice  simulating  yellow  fever... 
Management  of  cases 
Nursing  in 

Occupation  of  patients  during  apyrexial  periods 
Onset  of  human  trypanosomiasis  confounded  with     ... 
Parasites  of 

Date  of  discovery     ... 
Development  of 

Endogenous  cycle 
Exogenous 
Sexual  in  mosquito 
Asexual  in  man 
Period  of  residence  or  exposure  before  attack  develops,  measure  of 

endemic  index 
Pigment  deposits  in,  proportion  of  bodies  showing,  determination 
of  endemic  index  by  ...  ...  ...  ...  ...  8, 

Prevalence  of,  in  localities 

Dependent  on  existence  of  mosquitoes  capable   of  trans- 
mitting 
Estimation  of  :  see  also  Ejidemic  index. 


82 

180 

66 

83,84 
65-86 

65 
66 

15 
73 
92 
81 


III 

38 

39-41 

38,  39 

132,  134 

48,  64 

225 

6,  8 
8 
8 

7.  8 
7,  8 


INDEX 


2^1 


Malaria :—  TAOE 

Prevention   of,  on  settlements,  by  separation  of  European  quarters       80 
Propagation  of,  requirements  for  ...  ...         ...         ...  68 

Prophylactic  measures  against   ...         ...         ...         ...         ...         ...       72 

Isolation  of  travellers  or  gangs  of  workers  from  mosquito 

haunts       72,  73 

Universal  and  continuous  administration  of  quinine  among 
possibly  infected  persons 
Reduction  in  amount  of,  methods  should  be  as  complete^as  possible 

Of  temperature  by  cold  bathing    .. 
Topographical  distribution 
Treatment 
Dietetic 

By  quinine 

Methods  of  administration 
Vomiting  in,  due  to  oral  administration  of  quinine   ...         ...  41 

Treatment     ... 
Working  strength  of  labour  gangs  affected  by 
Quartan    ... 
Diagnosis 
Pathology 
Toxins  of 
Treatment     ... 
Subtertian 

Albuminuria  in 
Algide  form  .. 
Blood-stasis  in 
Abdominal 
Cardiac... 
Cerebral 
Pulmonary 
In  children    ... 
Complications  and  sequelae 
Convulsions  in,  in  children... 
"Crescents" 
Diagnosis 

By  blood  examination... 
Effects  of  repeated  congestion 
Epistaxis  in  ... 
Glycosuria  in 
Haemorrhages  in 
Heart  failure  in 
Labial  herpes  in 
Nephritis  in  ... 
Neuralgia  in... 
Neuritis  in 
Paraplegia  in 
Pathological  anatomy 

Accumulations  of  parasites  in  capillaries  of  organs...  ...       33 

Deposit  of  pigment  in.  liver  and  spleen        ...         ...  •■32i  33 


74 
80 

41 
15 

34-38 
43 
34 

35-37 
42 
40 
81 
18 

19 
20 
20 
21 


28,  30 

27 

24 

26,  27 
28 

24,  26 

26 

24 

28 

26 

22,  30,  57,  62.  63 

30 

30 

29 

26 

28 

28 

29 

24 

28 

29 

28,30 

29 

32.34 


252  INDEX 

Malaria  :  Subtertian  : —  page 

Pernicious  manifestations  of          ...         ...         ...  ...  ...       24 

"  Petit  mal"  in        29 

Prognosis      ...         ...         ...         ...         ...         ...  ...  ...31.  32 

Pyrexia  of    ...         ...         ...         ...         ...         ...  ...  ...22,23 

Toxic  effects...         ...         ...         ...         ...         ...  ...  ...29,30 

Treatment  by  quinine         ...         ...         ...         ...  ...  ...       34 

Vomiting  in  ...         ...         ...         ...         ...         ...  ...  ...       23 

Tertian,  benign    ...         ...         ...         ...         ...         ...  ...  ...       16 

Diagnosis          ...         ...         ...         ...         ...  ...  ...       17 

Geographical  distribution       ...         ...         ...  ...  ...       16 

Pathology          ...          ...          ...          ...          ...  ...  ...       20 

Symptoms         ...         ...         ...         ...         ...  ...  ...       16 

Toxins  of          ...         ...         ...         ...         ...  ...  ...       20 

Treatment         ...         ...         ...         ...         ...  ...  ...       21 

Man,  intermediate  host  only  known  for  malarial  parasites  ...  ...       68- 

Manson,  Sir  P.,  K.C.M.G.,  F.R.S.,  one  of  the  founders  of  English 

tropical  schools        ...         ...         ...         ...         ...  ...  ...     226 

Mansonia         ...         ...         ...         ...         ...         ...         ...  ...  ...     234 

Marchand  and  Simond  on  transmission  of  yellow-fever  organism  ...     115 

Mastigophora,  origin  of          ...          ...          ...          ...          ...  ...  ...     Ill 

See  also  Flagellata. 

Megarhinina    ...          ...          ...          ...          ...          .  .          ...  ..  ...     232 

Mental  depression  in  malarial  cachexia       ...         ...         ...  ...  ...       45 

Mercury,  bichloride,  with  carbonate  of  soda,  in  treatment  of  yellow  fever     112 

Metallic,  in  lanolin,  intramuscular  injections  of,  in  syphilis  ...  ...     201 

Perchloride  of,  in  treatment  of  blackwater  fever        ...  ...  ...       9S 

Merozoites        ...         ...         ...         ...         ...         ...         ...  ...»      ...       54 

Metazoa            ...         ...         ...         ...         ...         ...         ...  ...  ...       11 

Development  in  insects  ...         ...         ...         ...         ...  ...  ...       la 

Methylene  blue,  altered  (red),  in  Leishman's  stain            ...  ...  ...60,  61 

Unaltered,  in  Leishman's  stain     ...         ...         ...  ...  ...       60 

Microgametes,  of  coccidia      ...         ...         ...         ...         ...  ...  .,.         4 

Of  malarial  parasites           ...         ...         ...         ...  ...  ...       55 

Micropyle  of  macrogamete     ...         ...         ...         ...         ...  ...  ...    4,5 

Milk,  and  milk  and  barley  water,  in  malaria         ...         .,.  ...  ...       43 

Minchin,  development  of  trypanosomes      ...         ...         ...  ...  ...     141 

Mines,  gangs  at,  prevention  of  syphilis  among       ...         ...  ...  ...     202 

Monadina         ...         ...         ...         ...         ...         ...         ...  ...  ...     169 

Mosquitoes,  conveyance  of  malaria  parasites  from  man  to  man  by  ...       15 

Development  of  malaria  parasite  in      ...         ...         ...  ...  ...         7 

Sexual           ...         ...         ...         ...         ...         ...  ...  ...    7,  8 

Existence  of  species   capable  of  transmitting   malaria  determines 

endemic  prevalence  of  disease           ...         ...  ...  ...       66 

Extirpation  of,  methods  for        ...          ...          ...          ...  ...  ...77-80 

Harbourage  by  irrigation  systems,  avoidance  of         ...  ...  ...       80 

Haunts  of,  prophylaxis  of  malaria  by  avoidance  of   ...  ...  ...72,73 

Larvae  of,  methods  of  destruction  in  water     ...         ...  ...  •••77)78 

Malaria-carrying,  extermination,  methods  of  .. .         ...  ...  .••74j7S 

Drainage       ...         .„         ...         ...  ...  •••75"77 


INDEX 

Mosquitoes :  — 

Propagation  of  malaria  l)y,  proofs 

Geographical  distribution  of  species 
Success  of  prophylactic  measures 

Protection  from  bite  of  ... 

Ensures  freedom  from  malaria 

Trypanosomes  in... 
Mouth,  nose,  and  pharynx,  destructive  ulceration  of,  following  yaws 
Mouth-parts  of  Ixodes 

Of  Oniithodorus  ... 

Oi  Rhipicephalus...         ...         ...         ...         ... 

Mucidtis 
Musca  doinestica 
MuscidtT 

Myxosporidia,  origin  of 
Myzomyia 

Species  of,  carriers  of  malaria  ... 

fmiesta,  commonest  carrier  of  malaria  in  blackwater  fever  loca' 
Myzorhynchus... 


i; 


253 

66 

66 

67 

72 

66 

26,  127 

,     208 

229 

231 

,     230 

234 

•     237 

237 

II 

■     234 

74.  75 
ities      102 
...     2;6 


Nagan A,  causal  organism,  Trypanosoma  brucei  ...  ...  ...  ...     130 

G.  morsitans,  carrier  of . . .          ...         ...  ...  ...  ...  .  ■  •     138 

Nematocera       ...         ...         ...         ...         ...  ...  ...  ...  ...     227 

aiiomala     ...         ...         ...         ...         ...  ...  ...  ...  227,  236 

vera            ...         ...         ...         ...         ...  ...  ..  ...  227,231 

Neosporidia,  origin  of...         ...         ...         ...  ...  ...  ...  ...        11 

Reproduction  of  ...         ...         ...         ...  ...  ...  ...  ...        14 

Nephritis  in  subtertian  malaria          ...         ...  ...  ...  ...  ...       28 

Neuralgia  in  malarial  cachexia          ...         ...  ...  ...  ...  ...       45 

Neuration  of  wing  of  C^^/zV/i/fZ          ...  ...  ...  ...  ...     232 

Neuritis  in  subtertian  malaria            ...         ...  ...  ...  ...  28,  30 

New  Orleans,  prophylactic  measures  against  yellow  fever  at  ...  ...      121 

Nose,  pharynx,  and  mouth,  destructive  ulceration  following  yaws  ...     208 

Nyssorhynchus...          ...          ...          ...          ...  ...  ...  ...  ...     236 


Obermeier,  discovery  of  parasite  of  relapsing  fever 

Edina   ... 

Oocysts 

Ookinet 

.Formation  of 

Motile  eggs 

Nucleus  of 
Oriental  sore    ... 

Diagnosis  ... 

From  syphilis 

Etiology    ... 

Inoculation  against 

Mode  of  onset 


...     182 

232,  234 
...  5>  7 
59.  126 

124,  126 
7 


125, 


126 
167 
171 

171 
169 
170 

16S 


.  254  INDEX 

Oriental  Sore  :  —  page 

Parasite  of            ...         ...         ...         ...         ..,         ...  ...  ...  169 

Similarity  to  that  of  kala-azar        ...          ...          ...  ...  ...  169 

Pathological  anatomy      ...          ...          ...          ...          ...  ...  ...  168 

Prevalence  in  children    ...          ...          ...          ...          ...  ...  ...  170 

Prophylaxis  against          ...          ...          ...          ...          ...  ...  ...  171 

Treatment...          ...          ...          ...          ...          ..  ...  171 

By  copper-sulphate  solution            ...          ...          ...  ...  ...  171 

Ornithodorns  "...          ...          ...          ...          ...          ...          ...  ...  ...  230 

Mouth- parts  of 231 

Moubata,  description  of...          ...          ...          ...          ...  ...  194,  196 

Distribution  does  not  correspond  with  that  of  blackwater  fever  104 

Prophylaxis  against...          ...          ...          ...          ...  ...  196,  197 

'Yx2.\\%xm'i&\oxi  oi  Spirochata  duttoni  \yy    ...          ...  ...  ...  185 

Transmission  of  tick  fever  by        ...          ...          ...           190,    191,  193 

Savignyi   ...          ...          ...          ...          ...          ...          ...  ...  ...  195 

Orthorrhapha  ...          ...          ...          ...          ...          .;.          ...  ...  ...  227 

Overcrowding  and  dirt  favourable  to  spread  of  relapsing  fever  ...  ...  187 

Panama  canal  works,  prophylactic  measures  against  yellow  fever  at     ...     121 
Paralysis,  facial,  following  tick  fever  ...  ...  ...  ...  ...      192 

General,    of   insane,    similarity    of    cerebral    changes   in    sleeping 

sickness  to  those  of  ...         ...         ...  ...  ...         ...     135 

Paranghi :  see  Yaws. 
Paraplegia  in  subtertian  malaria 
Parasites,  animal,  infection  of  insects  with... 
Methods 
Influence  distribution  of  tropical  diseases 
Intermediate  hosts  of,  distribution 

Malarial 

Accumulations  in  capillaries  of  organs  found  posi  inortem 
Determination  of  proportion  of  inhabitants  infected  with 
Discovery  by  blood  examination  ... 
Man  the  only  known  intermediate  host  for 
Preparation  of  blood-films  for  examination  of     ... 
Ring  form     ... 
Vesicular  nucleus     ... 
Subtertian     ... 

Classification     ... 

Differences  from  other  forms...         ...         ... 

Sexual  development    ... 
Toxic  effects     ... 
Tertian  (benign),  quartan  and  subtertian,  differences  between, 
table  showing 
And  quartan,  benign  ...  ...  ...  ... 

Chromatin  nodules  seen  in         .., 

Sexual  multiplication      ...         ...         ...         ... 

Sexual  phase 


...     29 

9 

...  9,  10 

I 

I 

...48-64 

■••   33 

...   81 

...   31 

...   68 

...   49 

...   61 

...   61 

...56-59 

...62,63 

.-■   57 

•■.58,59 

...63,64 

...   56 

...50-54 

...   61 

..■;    54 

•.•-    54 

INDEX 


-DD 


Parasites  :  Malarial  :—  vack 

x\sexual  development  ...          ..           ...         ...         ...  •■•52,53 

Measurements  of...          ...         ,..           ..         ...         ...         ...  226-227 

Origin  of 10,  1 1 

See  also  iindei-  names  of  species  and  under  names  of  diseases. 

Parotid  gland,  swelling  and  inflammation  in  relapsing  fever         ...  ...      178 

Important  in  differentiation  from  plague          ...          ...          ...  ...      178 

Pediculus  veslimentorum         ...          ...           ..          ...          ...          ...  ...      i86 

Presumed  cause  of  epidemic  among  school  cliildren  in  India  ...     185 

Pellagra,  human  trypanosomiasis  mistaken  for  in  early  stages      ...  ...      134 

"  Petit  nial  "  in  subtertian  malaria  ...          ...          ...          ...          ...  ...       29 

Petroleum,  destruction  of  mosquito  larva;  by           ...          ...          ...  ...       77 

Pharynx,  mouth  and  nose,  destructive  ulceration  following  yaws  ...     208 

Pigment,  deposits  in  liver  and  spleen  found /^5/  mortem  in  malaria  •••32,  33 

Percentage  of  bodies  showing  deposits  of,  determination  of  malarial 

endemic  index  by  .  ...         ...         ...         ...         ...         ...  ..84,85 

Presence  of  in  liver  and  spleen  in  black  water  fever    ...         ...  ...       96 

Pigmentation,  cutaneous  in  kala-azar...         ...         ...         ...         ...  ...     152 

Piroplasma        ...         ...         ...         ...         ...         ...         ..           ...  ...     108 

Life  history  of      ...         ..           ...         ...         ...         ...         ...  ...     105 

In  native  cattle,  universal  infection       ...         ...         ...         ...  ...     107 

Not  associated  with  blackwater  fever  ...          ...         ...         ...  87,  104 

Origin  of  ...         ...         ...         ...         ...         ...         ...         ...  ...        11 

Points  of  difference  from  hremamoeba  ..           ...         ...         ...  ...     105 

Reproduction  and  hosts  ...         ...         ...         ...         ...         ...  ...       13 

Piroplasmosis    ...          ...          ..,          ...          ...          ...          ...          ...  105- 108 

Affecting  cattle,  immunization  against  rinderpest  leading  to  ...     107 

Affecting  cattle,  sheep,  horses  and  dogs          ...          ...          ...  105,  ic6 

See  also  liedwater fever.  Heart  Fever,  Jaundice,  epidemic. 

Htemoglobinuria  in          ...         ...         ...         ...         ..           ...  ...     106 

Hemolysis  in       ...         ...         ...          ...         ...         ...         .  .  ...     106 

Transmission  by  ticks     ...         ...         ...         ...          ...         ...  ...     103 

Plague,  differential  diagnosis  from  relapsing  fever...         ...         ...  17S,   iSo 

Plantations,  absence  of  malaria  on,  under  efficient  drainage         ...  ..         77 

Drainage  of,  in  extirpation  of  mosquitoes        ...         ...         ...  "]%,  79 

Prevention  of  syphilis  on           ...         ...         ...         ...          ...  ...     202 

Pneumonia  in  kala-azar          ...         ...         ...         ...          ...         ...  ...     152 

In  relapsing  fever             ...          ...           ..          ...          ...          ...  176,    178 

In  tick  fever         ...         ...         ...         ...         ...         ...         ...  ...     192 

See  also  Lung,  pneumonic  consolidation. 

Pregnancy  during  malaria       ...          ...          ...          ...          ...          ...  ...       43 

Prevention  of  abortion    ...          ...         ...         ...         ...  43,  44 

Protista  11 

Protozoa            ...         ...         ...          ...         ...         ...          ...         ...  ...  2,  11 

Development  and  life  history    ...         ...         ...          ...          ...  ...         4 

In  insects      ...         ...         ...         ...         ...         ...         ...  ...       10 

Groups  of...          ...         ..,          ...         ...         ...          ...         ...  ...         3 

Infection  of  rabbits  by    ...         ...         ...         ...         ...         ...  ...         6 

Intestinal  ...         ...         ..           ...         ...         ...         ...         ...  ...     217 


256  INDEX 

Protozoa  : —  PAGE 

Multiplication,  asexual  and  sexual        ...         ...  ...         ...         ...         4 

Spirochetes  classed  as    ...          ...          ...          ...  ...          ...          ...      186 

Unicellular  organisms     ...          ...          ...          ...  ...          ...          ...          2 

See  also  Ciliata  (Infusoria),  Sarcodina,  Flagellata  (Mastigophora),  Sporozoa. 

Pudenda,  granuloma  of :  see  also  tmder  Granuloma  ...         ...         ...     212 

Puru :  see  Yaius, 

Pupipara           ...          ...          ...          ...          ...          ...  ...          ...          ...     228 

Pyretophortis     ...          ...          ...          ...          ...         ...  ...          ...          ...     234 

Quinine,   administration,    universal    and   continuous  among    possibly 
infected  persons  in  prophylaxis  of  malaria 


Poisoning  by,  supposed  exciiing  cause  of  black  water  fever  ., 
Prophylactic  value  against  malaria 

Resistance  to  effects  of,  means  of  diagnosing  kala-azar  from 
Salts  of,  equivalent  doses 
Percentages  of  alkaloid 
Solubility  in  water  ... 
In  treatment  of  blackwater  fever,  sometimes  injurious 
When  only  permitted  ... 
Of  malaria    ... 

Dosage :    restriction  in  patients  previously  sufferin 

blackwater  fever  ... 
Ill-effects  of  prolonged  use      .. 
Methods  of  administration    ... 
Injections,  intramuscular 
Precautions 
Intravenous  ... 
By  mouth  ... 
By  rectum... 
Of  human  trypanosomiasis,  useless 
Of  yellow  fever,  no  effect  ... 
Bihydrobromate   .., 
Bihydrochlorate,    administration  by  rectal  injections  in  mal 
Ethyl  carbonate,  advantages  of... 
Hydrobromate 
Hydrochlorate,  administration  by  injections  in  malaria 

Rabbits,  protozoal  infection  of 

Rats,  presence  of  Trypanosoma  lewisi  in  enormous  numbers  in 

Rectal  injections  of  quinine  in  malaria 

Red-water  fever,  date  of  discovery    ... 

In  cattle    ... 

Produced  by  immunizing  process  against  rinderpest 
Reed  and  Carroll,  infective  agent  in  yellow  fever  ... 
Relapsing  fever 

Abortion  in 

Blood  examination  in 

Clinical  course 

Complications 


102, 


malaria 


74 
103 

72 
153 

34 

•  34 
34 

97,  98 
98 
37 
g  from 

44 
.       46 

•  34-37 
36,  42 

37 

37 

35 

■35.36 

•  13s 
112 

35 
35 
34 
35 
35 

6 

•  130 
■  35-,36 
.     225 

106 
107 
.  114 
189 
178 
180 

173 
178 


172 


178, 
i8o, 
179. 
178, 
181, 


INDICX 

Relapsing  fever  :  Diagnosis  ... 

]5y  discovery  of  Spirillitin  ohcniicieri  in  hlood 

From  malaria 

From  plague 
Enlargement  of  liver  and  spleen  in       ...         ...         ...  177, 

Epigastric  discomfort  in ... 

Etiology    ... 

Geographical  distribution 

Hoemorrhage  (epistaxis  and  hccmatemesis)  in  ... 

Heart  failure  in    ... 

Immunity  to,  acquirement  of     ... 

Interdependence    between    presence   of   spirochtetes   and   differen 

phases  of 
Jaundice  in 

Liability  to  attack  of  attendants  on  sick 
Morbid  anatomy  ... 
Mortality  from 
Parasite  of  ...         ...         ...         ...         ...         ...         ...        129, 

Pneumonia  in       ...         ...         ...         ...         ...         ...  ...        176, 

Pneumonic  consolidation  in 

Prevalence  greatest  among  unclean  and  overcrowded  populations 

Prognosis  ... 

Unfavourable  when  complicated  by  pneumonia  or  jaundice 
Prophylaxis  against 

By  disinfectant  measures    ... 
Pulse  in     ... 

Quarantine  of  patients    ... 
Resemblance  of  tick  fever  to    ...         ...         ...         ...         ...        19 

Ship  infection  in  ... 

Sweating  during  crisis     ... 

Swelling  and  inflammation  of  parotid  gland  and  lymphatic  glands 

Symptoms  of  relapse 

Temperature  in,  sudden  rise  and  fall    ... 

Thirst  in    ... 

Treatment  187, 

Dietetic 

Of  heart  failure  in  ... 
Urine  in    ... 
Varieties  of,  contrasted  ... 

Differences  in  parasites 
Vomiting  in  ...         ...         ..  ..         ...         ...         ...        173, 

African  :  see  Tick  fever. 
Remittent  fever,  bilious,  with  jaundice,  blackwater  and  yellow  fevers 

mistaken  for 
Rhipicephalus ,  mouth  parts  of 

Rinderpest,  immunization  against,  in  cattle  leading  to  piroplasmosis  in- 
fection 
Ring  form  of  malarial  parasites 

18 


79 
82 
80 
80 
82 

77 
82 
72 
78 
75 
85 

[84 
177 
[87 
[81 
(79 
182 
[78 
[82 
t87 
[79 
[79 


'75 
.89 
192 
[87 
[77 
[78 
[72 

'74 
[76 
188 
[88 
1 88 

177 
167 
198 
[76 


112 

230 


107 
61 


258  ,  INDEX 


Rogers,  L.,  diagnosis  of  kala-azar    ... 

Etiology  of  kala-azar 

Seasonal  prevalence  of  kala-azar 
Romanowsky's  method  of  staining   ... 
For  parasite  of  kala-azar    ... 

Leishman's  modification... 
Roof  gutters,  cleansing  in  prophylaxis  of  yellow  fever      ...         ...         ...     120 

Hatching  place  for  eggs  of  6". /aji^/fl/fl; ...         ...         ...         ...         ...     119 


PAGE 
...  150 
161,  162 
...  164 
183,  184 
157,158 
...       49 


St.  Vincent,  prevalence  of  malaria  in,  reason  for           ...         ...  ...       66 

Saline  solution,  rectal  enemata  of,  in  treatment  of  blackwater  fever  98,  100 

Sanarelli,  bacillus  associated  with  yellow  fever,  discovered  by     ...  ...     114 

Sarcodina          ...         ...         ...         ...         ...         ,.,         ...         ...  ...         3 

Group  of  protozoa           ...         ...         ...         ...         ...         ...  ...         3 

Origin  of  ...         ...         ...         ...         ...         ...         ...         ...  ...       11 

Sarcopsj///a peneirans  {chigoe)  cati'ier  oi ya.v/s        ...         ...         ...  ...     211 

Sarcosporidia,  origin  of          ...         ...         ...         ...         ...         ...  ...       il 

Schaudinn,  classification  of  protozoa...         ...         ...         ...         ...  ...         3 

Discovery  oi Spirochceta pallida  as  causal  agent  of  syphilis  ...  ...     186 

On  halteridium    ...         ...         ...         ...         ...         ...         ...  123,124 

Spirochsetes  classed  as  protozoa  by       ...         ...         ...         ...  ...     186 

On  trypanosomes  ..         ...         ...         ...         ...         ...         ...  ...     124 

Schizogony        ...         ...         ...         ...         ...         ...         ...         ...  ...       54 

Schizonts          ...         ...         ...         ...         ...         ...         ...         ...  ...       54 

Asexual  forms  of  coccidia           ...         ...         ...    ^     ...         ...  ...         4 

Schizophora      ...         ...         ...         ..,         ...         ...         ...         ..  ...     228 

Schiiffner's  dots  seen  in  benign  tertian        ...         ...         ...         ...  ...       61 

Settlements,    drainage,    clearance    and    cultivation    in    extirpation  of 

mosquitoes        ...         ...         •••78,79 

Prevention  of  malaria  in,  by  separation  of  coolie  lines  and  European 

quarters...         ...         ,.,         ...         ...         ...         ...  ...       80 

Septicaemia  in  geese  produced  by  6'/^>27/2^OT  a;^^^;/;/?        ...         ...  ...     185 

Serum  of  hyperimmunized  animals  in  treatment  of  relapsing  fever  ...     188 

Sheep,  piroplasmosis  in          ...         ...         ...         ...         ...         ...  105,106 

See  also  Heart  fever. 

Ship,  epidemics  of  yellow  fever  on  board    ...         ...         ...         ...  ...     122 

Importation  of  yellow  fever  usually  by...         ...         ...         ...  121,122 

Ship-infection  in  relapsing  fever        ...          ...          ...          ...          ...  ...      187 

Simond  and  Marchand  on  transmission  of  yellow-fever  organisms  ...     115 

Siphonaptera    ...         ...         ...         ..           ...         ...         ...         ...  ...     228 

Skin,  bronzing  of,  in  malarial  cachexia        ...         ...         ...         ...  ...       45 

Diseases  of,  and  malaria            ...         ...         ...         ...         ...  ...       47 

Sleeping  sickness,  cerebral  changes ...         ...         ...         ...         ...  ...     135 

Discovery  of  trypanosomes  in  cerebrospinal  fluid  by  lumbar  puncture     134 
Fatal  cerebral  symptoms  of        ...  ...  ...  ...    131,  133,  134,  135 

Terminal  stage  of  human  trypanosomiasis       ...         ...   131,  133,  134,  135 

See  also  Trypanosomiasis,  human. 


2.S9 

I'A';k 
1 08 

112 

.  98 
94.  95 
.  185 
.  185 


...  185 
182,  183 
129,  182 
...  225 
...  180 
...  185 
190,  191 
225,  226 
210 
225 
210 


186, 


22: 


of 


INDEX 

Smith,  on  bodies  resembling  piroplasma,  found  in  severe  forms  of  malaria 
Soda,  carbonate  of,  with  perchloride  of  mercury 
In  treatment  of  yellow  fever 
In  treatment  of  black  water  fever 
Spectroscope,  aid  in  diagnosis  of  blackwater  feve 
Spirillum,  species  of,  conveyed  by  bite  of  ticks 
anserini  cause  of  septicemia  in  geese  ... 
duttoni :  see  SpirocJuvla  duttoiti. 
gailinarum  transmitted  Ijy  Argas  pcrsiais 
obernieieri,  description  of 

Causal  organism  of  relapsing  fever 
Date  of  discovery    .., 

Presence  in  blood  diagnostic  of  relapsing  fever 
/A«?VeA-2  affecting  cattle    ... 
Spirochata  duttoni      ...       '  ...         ...         ...         ...         ...    129,  1^5, 

Date  of  discovery 

pallida,  causal  organism  of  syphilis 

Date  of  discovery    ... 
pertenuis,  association  with  yaws 
Date  of  discovery    ... 
Spirocha;t£e 

Classed  as  protozoa 

Interdependence    between    presence    of    and    different   phases 

relapsing  fever 
Present  in  blood  in  tick  fever    ... 
In  tissues,  diseases  associated  with 

See  also  Granuloma  of  pudenda,  Syphilis,  and  P 
Spleen,  deposits  of  hemosiderin,  in  blackwater  fever 

Of  pigment  found  post  mortem  in  malaria 
Enlargement  of,  examination  for,  method  of  testing  endemic  index 
in  malaria 

Percentage  error  in  application  of  test  for    . 
In  human  piroplasmosis      ...         ...         ...         ...         ■••        107, 

In  kala-azar 147,148,151,155, 

In  malaria    ...         ...         ...         ...         ...         ...         ...         .•■       33 

In  malarial  cachexia  ...         ...         ...         ..  •••         ■•.       45 

In  relapsing  fever    ...         ...  ...         ...         ...         ...        I77>   iSi 

Chronic,  in  subtertian  malaria      ...  ...         ...         ...  ...       29 

In  tick  fever 192 

Pigment  present  in,  in  blackwater  fever 

Seat  of  parasite  in  kala-azar      ...  ...  ...         ...         •••         ■•.     156 

Splenomegaly  (tropical),  see  Kala-azar, 

Sporogony         59 

Sporozoa,  classification  of      ...         ...         ...         ...         ...         ..•         ■•■       12 

Group  of  protozoa  ...         ...         ...         ...         •••  -.         •••         3 

Origin  of...  ...         ...         ...         ...         ...         ••.         •••         •••       n 

Sporozoites       7,  59 

Formation  in  coccidia     ...         ...         ...         ...         ...         ...         ...         5 


.      184 

■      193 
199 

•       96 
32,  33 

83,  84 
.  86 
108 
165 


26o  •  INDEX 

PAGE 
Staining,  processes  of,  in  preparation  of  blood-films         ...         ...         ...       50 

See  also  Romanoivsky' s  method. 
6'/if^(?;;y?'(2,  genus,  characteristics  of ...         ...         ...         ...  ...         ...     115 

Stegotnyia fasciata,  breeding  places  ...         ...         ...         ...   116,  117,  118,  119 

Knowledge  of,  essential  in  prevention  of  spread  of  yellow  fever      ...     119 
Characteristics  of  ...         ...         ...         ...         ...         ...         ...     116 

Destruction  by  fumigation  on  board  ship         ...         ...         ...         ...     122 

Eggs  of      116 

Extreme  vitality      ...         ...         ...         ...         ...         ...         ...     116 

Habitats  of  118 

LarvEe  of ...         ...         ...         ...         ...         ...         ...     117 

Protection  from  bites  of ...         ...         ...         ...         ...         ...         ...     113 

Transmission  of  yellow  fever  by  109,114 

Conditions  necessary  for     ...         ...         114 

Stomach,  congested  state  of  in  yellow  fever  113,114 

Stomoxys  ..  ...         ...         ...         ...         ••.         ...     238 

calcitrans  ...         ...         ...         ...         ...         ...         ...         ...         ...     237 

Surra 130 

Sweating  in  relapsing  fever  during  crisis      177 

Syphilis,  treatment  by  intramuscular  injections  of  metallic  mercury  in 

lanolin  ...         ...         ...         ...         ...         ...         ...         ...     201 

Causal  organism  (presumed),  Spirochata  pallida        ...  129,  186,  210 

Diagnosis  of  oriental  sore  from ...         ...         ...         ...         ...         ...     171 

Of  yaws  from  ...         ...         ...         ...         ..  ...         ...     208 

Does  not  protect  from  yaws       ...         ...         ...         ...         ...         ...     211 

In  Indian  army  ...         ...         ...         ...         ...         ...         ...         ...     200 

Secondary  and  tertiary  fever  in...         ...         ...         ...         ...         ...     200 

Points  of  similarity  to  yaws       ...         ...         ...         ...         ...         ..      209 

Recurrence  induced  by  malarial  cachexia        ...         ...         ...         ...       45 

In  Tropics,  prophylaxis ...         ...         ...         ...         ...         ...         ..      202 

Nature  of      ...         ...         ...         ...         ...         ...         ...         ...     199 

Spread  among  women        ...         ...         ...         ...         ...         202,203 

Treatment 201 

Tabanus,  wing  of        ...         ...         ...         ...  ...  ...  237 

Tanks,  clearing  of,  in  prophylaxis  of  yellow  fever...  ...  ...  ...  120 

Hatching  place  for  eggs  oi  S.  fasciata...  ...  ...             117,  118,  119 

Tea,  hot,  as  drink  in  malaria             ...         ...  ...  ...  ...  ...  43 

Telosporidia      ...          ...          ...          ...          ...  ...  ...  ...  , . .  12 

Origin  of   ...          ...          ...          ...          ...  ...  ...  ...  ...  il 

Thirst  in  relapsing  fever         ...         ...         ...  ...  ...  ...  ...  176 

Tick  fever         190-198 

Bronchitis  and  pneumonia  in     ...         ...  ...  ...  192 

Causal  orgSLuism,  Splroc/icFla  dttllom    ...  ...  ...   129,185,  190,  191 

Diagnosis  ...         ...         ...         ...         ...  ...  ...  ...  ...  192 

Enlargement  of  liver  and  spleen  in       ...  ...  ...  ...  ...  192 

Etiology    ...         ...         ...         ...         ..  ...  ..  ...  ...  193 

Facial  paralysis  after       ...         ...         ...  ...  ...  ...  ...  192 


INDEX  261 

Tick  fever  : —  I'Agk 

Historical  account  of       ...         ...         ..  ...         ...         ...         ...     190 

Incidence  on  Europeans...         ...         ...  ...         ...         ...         ...     192 

Incuhalion  period  ...  ...  ...  ...  ...  ...  ...      192 

/WA/ywr/ew  appearances  in  animals    ...         ...  ..         ...         ...      193 

Prophylaxis  ...         ...         ...         ...         ...         ...         ...         ...      194 

Resemblance  to  relapsing  fever  ...         ...         ...  ...  191,  192 

Spirochfctes  present  in  blood     ...         ...         ...         ...  192,  193,  194 

Symptoms  ...  ...         ...         ...         ...         ...  ..  191,  192 

Tisinsmiss'ion  hy  Omi^/iodorus  Motidaia  ...  ...  190,  191,  193 

Points  of  importance  respecting    ...         ...         ...         ...         ...     194 

Treatment..,         ...         ...         ...         ...         ...         ...  ..         ...      194 

Ticks      ...         ...         ...  ...         ...         ...         ...         ...         ...         ...     229 

Transmission  of  piroplasmosis  by         ...  ...  ...         ...         ...     105 

Tictin,  on  experiments  with  spirillum  ...         ...         ...         ...         ...     184 

Todd,  on  course  of  tick  fever  ...         ...         ...         ...         ...         190,  191 

Toxins,  effects  of,  in  subtertian  malaria       ...         ...         ...         ...  29,   30 

Trade  routes,  destruction  of  (7/(?j'JzV;rt  along  ...         ...  ...         ...      143 

Treponema,  description  of     ...         ...         ...  ...         ...         ...         ...     129 

palliduju  :  see  Spirochata  pallidutii. 
Trichofiionas,  date  of  discovery        ...         ...  ...  ...         ...         ...     225 

Tropical  fever :   see  Malaria,  subtertian. 
Trypanoplasma  of  fish 
Trypanosoma  brucei   ... 

Causal  organism  of  nagana 
(Tr^^sz  found  in  man 

dimorphon  occurs  in  cattle  and  horses... 
e(('?<?/5e;'i^«;;;,  causal  organism  of  dourine 
£z;a«j/,  causal  organism  of  surra 
gainbiense 

Found  in  man 

Presence  of,  in  blood,  cause  of  trypanosomiasis 
/ijwzV?  present  in  rats  in  enormous  numbers    ... 
noctticE 
theileri 
Trypanosoines : — 

Date  of  discovery 

Degenerate,  resemblance  of  Leishman-Donovan  bodies  to  ... 

Description  of 

Development  of  ...         ...         ...         ...         ...         ...  125, 

Discovery  in  cerebrospinal  fluid  by  lumbar-puncture  during  sleeping 

sickness 
Gregariniform  stage  of    ... 
Life  cycle  of 

In  mosquitoes 
In  owl 
Trypanoplasma  of  fish  and  Herpetomonas  differ  from 
Trypanosomiasis 
Etiology    ... 


128 

162 

130 

130 

130 

130 

130 

13', 

138 

130 

131 

130 

124 

130 

225 

128 

128 

126, 

141 

)ing 

134 

126, 

127 

126, 

127 

126, 

127 

127 

128 

129 

137 

262  INDEX 

Trypanosomiasis : —  page 

Rash  in      ...         ...         ...         ...         ...         ...         ...         ...  ...     132 

Human      ..,          ...          ...          ...          ...          ....         ...          ...  131-143 

Clinical  history        ...         ...         ...         ...         ...         ...  ...     132 

Diagnosis      ...         ...         ...         ...         ,..         ...         ...  ...     134 

Enlargement  of  lymphatic  glands  in         ...         ...         ...  ...     132 

Geographical  distribution  ...         ...         ...         ...         ...  ...     131 

Grissoli's  symptom  ...         ...         ...         ...         ...         ...  ...     132 

Nursing         ...          ...          ...          ...          ...          ...          ...  ...      137 

Onset  confounded  with  malaria     ...         ...         ...-        ...  ...     132 

Pathological  anatomy          ...          ...          ...          ...          ...  ...      134 

Possible  connection  of  kala-azar  with      ...         ...         ...  160,   161 

Possible  occurrence  in  India          ...         ...         ...         ...  ...     160 

Prognosis      134,   135 

In  early  stages  favourable,  in  later  stages  (sleeping  sickness) 

fatal  ...      - 135 

Prophylaxis  ...         ...         ...         ...         ...         ...         ...  140,   142 

Among  Europeans  easy,  among  natives  difficult    ...  ...     143 

By  destruction  of  fly  along  trade  routes      ...         ...  ...      143 

Treatment     ...         ...         ...         ...         ...         ...         ...  ...     135 

By  antimony  injections           ...         ...         ...         ...  ...     137 

By  atoxyl  injections     ...          ...          ...          ...          ...  ...      136 

Tsetse  flies  {see  also  Glossina  morsiians)      ...         ...         ...         ...  ...     138 

Tuberculosis,  malarial  patients  prone  to      ,,.         ...         ...         ..  ...       47 

Pulmonary,  in  kala-azar...          ...          ...          ...          ...          ...  ...      152 

Typhoid  fever,  human  trypanosomiasis  mistaken  for,  in  early  stages      ...     134 

Simulated  by  initial  fever  of  kala-azar...         ...         ...         ...  146,   147 

Transmission  by  flies      ...         ,..         ...         ...         ...         ...  ...       10 

Typhus  fever    ...         ..           ...         ...         ...         ...         ...         ...  107,   108 

Unicellular  organisms,  distinction  between  plant  and  animal  difficult 

to  define  in           .,.         ...         ...         ...          ..         ...         ...  ...         2 

See  also  Protozoa, 

Ureters,  blockage  of   ...         ...         ...         ...         ...         ...         ...  ...       93 

Urine,  blackwater  fever  diagnosed  from  state  and  colour  of         ...  ...       93 

In  relapsing  fever    ...         ...         ...         ...         ...         ...  ...     177 

Examination  in  blackwater  fever           ...         ...         ...         ...  88,91 

Similarity  in  colour  in  paroxysmal  hsemoglobinuria  to  that  in  black- 
water  fever        ...         ...         ...         ...         ...         ...  ...       93 

Suppression  of,  main  danger  in  blackwater  fever       ...         ...  93,  95,  100 

In  yellow  fever        ...         .  .         ,.          ...         ...         ...  1 11,  112 

Vesicular  nucleus  of  malarial  parasites    ...         ...         ...         ...  ...       61 

Victoria  Nyanza,  introduction  of  human  trypanosomiasis  into      ...  ...     131 

Vomiting  in  blackwater  fever           ...         ...         ...         ...         ...  89,  93,  100 

In  malaria,  due  to  oral  administration  of  quinine      ...         ..  ...41,42 

Treatment     ...         ...         ...         ...         ...           ..         ...  ...       40 

In  malaria  (subtertian)    ...         ...         ...         ...         ...         ...  ...       23 

In  relapsing  fever..,         ...         ...         ...         ...         i73j  176 

In  yellow  fever     ...         ...         ...         ...  no,  112,  114 


INDKX  263 

I'A<;k 

Water,  soluhilily  in,  of  sails  of  quinine 34 

Water-barrels,  halcliing  place  of  eggs  of  Slegoviyia  fasciata  1 16,  i  if<,  119 

Weil's  disease  simulating  yellow  fever          ...  ...  ...  ...  ...     iii 

Wing,  neuration  of,  characteristic  of  C«//V/c/(j  ...  ...  ...  ...     232 

Of  Tahaiius          ...         ...         ...         ...  ...  ...  ...  ...     237 

Women,  native,  emancipation  of,  cause  of  spread  of  syphilis  among  ...     203 

Wright,  parasite  of  Oriental  sore      ...         ...  ...  ...  ...  ...     169 

Yaws 203 

Breeds  true           ...         ...         ...         ...  ...  ...  ...  ...     210 

Carrier  of,  chigoe  (.V«;vv3/.y///«/t7;5/i''rt;/j)  ...  ...  ...  ...     211 

Clinical  course     ...          ...          ...          ...  ...  ...  ...  ...      204 

Diagnosis...          ...         ...         ...         ...  ...  ...  ...  ...     208 

Does  not  protect  from  syphilis  ...          ...  ...  ...  ...  ...     211 

Etiology    ...         ...         ...         ...         ...  ...  ...  ...  ...     209 

Geographical  distribution          ...         ...  ...  ...  ...  203,  204 

Granulomata  of  ...          ...         ...         ...  ...  ...  ...  .  .     207 

Pathological  anatomy     ...         ...         ...  ...  ...  ...  ...     209 

Prognosis...          ...         ...          ,..          ...  ...  ...  ...  ...     208 

Prophylaxis           ...          ...          ...          ..  ...  ...  ...  ...     21 1 

Sequela:     ...         ...         ...         ...         ...  ...  ...  ...  ...     208 

And  syphilis,  differential  diagnosis       ...  ...  ...  ...  ...     208 

Points  of  similarity  ...         ...         ...  ...  ...  ...  209,210 

Related,  but  identity  doubtful       ..  ...  ...  ...  ...     210 

Treatment            ...         ...         ...         ...  ...  ...  ...  ...     209 

Yellow  fever  : — 

Albuminuria  in     ...         ...         ...         ...  ...  ...  109,  no,  1 11 

Bacillus  associated  with  ...         ...         ...  ...  ...  ...  ...      ir4 

Clinical  course     ...         ...         ...         ...  ...  ...  ...  ..       no 

Stages  of       ...         ...          ...         ...  ...  ...  ...  ...      no 

Third  stage  the  most  dangerous     ...  ...  ...  ...  ...     in 

Congested  state  of  stomach  in  ...         ...  ...  ...  ...  nj,  n4 

Diagnosis..,         ...         ...         ...         ...  ...  ...  ...  ...     ni 

Differential,  from  blackwater  fever  ...  ...  ...  in,  n2 

Of  epidemic  form  easy,  of  isolated  cases  more  difficult ...  ...      n  i 

Epidemic  on  board  ship...         ...         ...  ...  ...  ...  ...      122 

Fatty  degeneration  of  liver  and  kidneys  in  ...  ...  ...  ...     n3 

Geographical  distribution           ...         ...  ...  ...  ...  ...     109 

Headache  in        ...         ...         ...         ...  ...  ...  ...  no,  112 

Importation  usually  by  ship      ...         ...  ...  ...  ...  121,  122 

lufectivity  of  blood  serum  from  patient,  extreme      ...  ...  113,  n4 

Jaundice  in          ...         ...         ...         ...  ...  ...  ...  109,  no 

Nursing     ...         ...         ...         ...         ...  ...  ...  ...  ...     n2 

Parasitology  unknown    ...         ...         ...  ...  ...  ..  109,  113 

Pathology  and  morbid  anatomy            ...  ...  ...  ...  ..       n3 

Prophylaxis  against        ...         ...         ...  ...  ...  ,..  ns,  122 

By  cleansing  roof  gutters  and  cisterns  ...  ...  ...  ...     120 

By  disinfection  of  premises...         ...  ...  ...  ...  ...     121 

By  notification  and  isolation  of  cases  ...  ...  ...  120,  121 


264  INDEX 

Yellow  fever  :—  page 

Simulated  by  acute  yellow  atrophy  of  liver,  malaria  with  jaundice 

and  Weil's  disease  ...         ...         ...         ...         ...         ...         ...     11 1 

Spread  of,  prevention  by  knowledge  of  breeding  places  of  Stegomyia 


fasciata 
Suppression  of  urine  in  ... 
Symptoms... 
Transmission  by  S.  fasciata 

Conditions  necessary  for 
Treatment... 

By  bichloride  of  mercury  and  carbonate  of  soda. 

By  ice-bags  or  cold  compresses  to  abdomen 
Vomiting  in  


"9 

III,  112 
...  109 
109, 114 

"4 

...  112 

112 

...  "3 

no,  112,  114 


Zygote 
Zygotomere 


59 
7 


Plate  1 . 


C     « 


5 


10 


.t'    " 


11 


12 


13 


14. 


15 


16 


17. 


18. 


19 


20 


23. 


24- 


A  Terzi   del 


26 


/« 


-Bale  &  Damelsao-c.I.'-^lLth. 


tigs. 
I  to  5, 
6, 
7,  8,  9 

10  to  15. 

16,   17, 

18. 

ig. 

24.  25 


PLATE  I. 

Stained  with  Leishman's  Stain. 

Stages  of  benign  tertian  parasite. 

Gamete  benign  tertian. 

Characteristic  degeneration  of  red  corpuscles  con- 
taining benign  tertian  parasites  (Schijffner's 
dots). 

Stages  of  quartan  parasite. 

Stages  of  malignant  tertian  (sub-tertian)  which 
are  seen  in  peripheral  blood. 

Male  gamete,  malignant  tertian  (sub-tertian). 

Female  gamete,  malignant  tertian  (sub-tertian). 

20.  Double  infection  with    malignant    tertian   (sub- 

tertian)  parasites  of  a  red  corpuscle  ;  baso- 
philic granules  in  red  corpuscle. 

21.  Trypanosoma  lewisi  (rat). 

22.  Trypanosoma  hominis  (Congo). 

23.  Spirillum  of  relapsing  fever  (stained  with  carbol 

fuchsin). 
Aiuffha  coll. 


PLATE   II. 

Stained  with  Leishman's  Stain. 

Figs. 

1.  Normal  red  corpuscle. 

2.  Blood  plates. 

3.  Lymphocyte. 

4.  Large  mononuclear  leucocyte. 

5.  Polymorphonuclear  leucocyte. 

6.  Eosinophile  leucocyte. 

7.  Mast  cell. 

8.  Transitional  form. 

9.  Abnormal   mononuclear    cell    found    in    certain 

diseases,  including  trypanosomiasis. 
10  to  13.     Myelocytes  showing  various  types  of  granules. 
14,    15.     Halteridium. 

16.  Small  drepanidium  in  red  corpuscle. 

17.  Same  drepanidium  in  plasma. 

18,    19,  20.     Large  drepanidium  in  various  stages. 

'  21.     Degeneration  of  red  corpuscle  caused  by  drepa- 
nidium (Schiiffner's  dots). 


Plate    II 


7. 


,  v*'^-? 


10. 


«^> 


fi*? 


U 


14. 


12. 


13 


15 


# 


16  . 

18. 

20  . 

.-. '  '•'■■ '  ■  »-V"».'  '-^ 

19 

A.Terzi    del 


21  . 

Bai.e  A-Danielsson  L'-.^  Mi. 


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